TALA
Individual Assistance Request Form
Please provide the following contact information:
Name
Street address
City
State
Zip Code
Work Phone
Home Phone
Cell Phone
Fax No.
E-mail
Occupation
Describe the nature of your problem:
Have you ever Consulted an Attorney or Accountant for this problem? Yes No
If "yes," please explain the current status of your relationship with this professional.
Financial Eligibility:
State your annual income (and that of your spouse, if you are married) for the last 2 years. This amount should include public assistance, Social Security, unemployment compensation and any other income-producing activity, whether or not derived from arts-related activities.
Applicant:
Year
Annual Income $
Spouse:
Attachment Checklist: Please mail or drop off the following information with your request form:
· Copies of tax returns from the last two years
· Copies of any documents relating to the specific problem for which you are seeking assistance (i.e., contracts, correspondence, etc.)
NOTE: TALA reserves the right to reject a client's application for assistance for a variety of reasons, including: (1) request from a non arts-related organization; (2) applicant's household income over income guidelines; (3) matter may require too much time to resolve on a volunteer basis; (4) unavailability of volunteer qualified to handle a particular request.
Please print out this form and submit to:
Texas Accountants and Lawyers for the Arts 1540 Sul Ross Houston, TX 77006
Date rec’d:______________ TY:_____________ DB:______________ Pd:_____________________
