Step 1 of 2 50% Is child under age 21?*YesNoIs child a US Citizen?*YesNoIn which county does the child reside?*Coffey County, KansasLyon County, KansasOsage County, KansasElsewhereHas child resided in the county continuously for a minimum of one year?*YesNoYour child is not eligible. Your child must be under age 21, must be a US Citizen and must currently reside in Coffey, Lyon, or Osage County Kansas and have done so continuously for no less than one year immediately prior to application. Return to Home PagePlease click Next to proceed with the assessment. Referred by:Child's Information (for whom you are applying):Click the plus sign at the right of the line below to add additional children, if needed.*NameAgeDate of BirthSex (M or F) Does Child have medical insurance?*YesNoIf yes, Insurance Name:Does Child have dental insurance?*YesNoIf yes, Insurance Name:Parent(s)/Legal Guardian(s) Household Information:Name* First Last Address* Street Address Address Line 2 City State ZIP Email* Preferred Phone Numer*This number is:CellHomeWorkMarital Status*MarriedDivorcedSeparatedWidowedSingle (never been married)Living togetherTotal Number of Children in household*Parent/Legal Guardian Employer*Hourly Wage*Hours per week*Pay Frequency*WeeklyBi-WeeklyMonthlySemi-MonthlySpouse/Partner InformationSpouse/Partner Name First Last Spouse/Partner EmployerHourly WageHours per weekPay FrequencyWeeklyBi-WeeklyMonthlySemi-MonthlyHousehold Income InformationDo you file taxes?*YesNoIf no, why not?*If yes, what is the exact amount of Adjusted Gross Income on your most recent return? This is NOT the Tax Refund amount.*Additional Household Income per month (if none, type $0.00):Cash Assistance (if none, type $0.00):*Child Support (if none, type $0.00):*Death Benefits (if none, type $0.00):*Disability (if none, type $0.00):*Food Stamps (if none, type $0.00):*Military (if none, type $0.00):*Retirement (if none, type $0.00):*SSI (if none, type $0.00):*Unemployment (if none, type $0.00):*Brief description of why you need our help: (Include dates of service, provider(s) name and treatment received/needed.)*AcknowledgementBy completing this form, you acknowledge and agree to the following statements: This form is an eligibility assessment only. This means that completing this form does NOT guarantee the Jones Foundation's grant of any financial grant to your child(ren). The information provided on this form may be reviewed by Jones Foundation staff and its board members to determine eligibility for your child(ren)'s financial grant. The information provided in this form is true and accurate to the best of your knowledge and belief. You understand that intentional misstatements or falsification will render your child(ren) ineligible for a grant.Electronic SignaturePlease Type your First and Last Name*Date Date Format: MM slash DD slash YYYY * I understand that checking this box constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the the information provided in this document.