Request Assistance

Women With Willpower provides one – time assistance to eligible women in our community, who are currently employed and experiencing a temporary financial hardship.

Submitting this request does not guarantee approval or financial assistance. Each request is reviewed individually based on eligibility, circumstances, documentation provided, and available funding. Assistance, when approved, is paid directly to the appropriate vendor or service provider.

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Name *

First

Last

Email *

Phone Number *

Address *

ZIP Code *

How long have you lived in Lake Havasu City? *--- Select Choice ---Less than 3 months3-6 months6-12 months1-3 years3-5 years5+ years

Household Members *

List each person in your household, their age, and relationship to you.

Current Employer *

Please provide the name of your current employer.

How long have you been with your current employer? *

Gross Monthly Income *

Enter your total monthly income from your current employment before taxes.

Child Support

Alimony

SSI / Social Security / SSDI

Disability Income

Retirement/Pension Income

Spouse/Partner Income

Roommate/Other Household Member Income

Government Assistance

Other Income

Amount of Assistance Requested *

Enter the dollar amount you are requesting.

When are the funds needed? *

Please enter the date the payment is due.

What are you requesting assistance with? *

Please describe the specific bill or expense you are requesting assistance with.

Have you contacted other available community resources? *

• Yes
• No

Women With Willpower is a last-resort resource. Please review the Community Resources page on our website and contact the appropriate organizations before submitting your request.

Resources Contacted *

List each resource you contacted, the date contacted, who you spoke with, and the outcome.

What caused your temporary financial hardship? *

Please explain what happened and why you are requesting assistance at this time.

How will this assistance provide a “hand up”? *

Please explain how this one-time assistance will help you become financially stable, moving forward.

Payee/Vendor Name *

Who should Women With Willpower pay if your request is approved?

Payee/Vendor Phone Number *

Payee/Vendor Address *

Account Number (if applicable)

Enter the account number associated with the bill or service, if applicable.

Vendor Contact Person *

Are you able to pay part of this bill? *

• Yes
• No

If yes, how much?

How did you hear about us?

Would you like to volunteer with WWW?

• Yes
• No

May we share your story?

• Yes
• No

Your answer will not affect your request for assistance.

Applicant Acknowledgement *

• I understand that submitting this request does not guarantee approval or financial assistance.

Certification *

• I certify that the information provided in this request is complete and accurate to the best of my knowledge.

Driver's License/Photo ID *

Drag & Drop Files, Choose Files to Upload

Please upload a copy of your Driver's License or Photo ID

Number been how

Pay Stubs/Proof of Income *

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Please upload a copy of your Pay Stubs or Proof of Income

Current Lease/Rental Agreement

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

Please upload a current Lease or Rental Agreement, if applicable.

Bill/Statement for Assistance Requested

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

Please upload your current Bill or Statement for Assistance Requested, if applicable.

Car Repair Estimate

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

Please upload the current repair estimate, if requesting car repair assistance.

Submit