Emergency Financial Assistance Fund (EFA)

Please contact the agencies below for additional support and services:

United Way 211 Needlink: https://www.needlink.org/ or 615/269-6835 Multiple Resources: www.nashvilleresponsefund.com/individuals Metro Action Commission – https://hub.nashville.gov/s/request-type/a0ut0000001GZ7DAAW/metro-action-commission-hope-application?language=en_US or 615/862-7368 Tennessee Community Action – https://www.tncommunityaction.org/ or 629/888-0233 COVID Related Resources – https://tncoalition.org/get-help/covid-19-resources/ EFA is available to domestic violence and sexual assault survivors from all Tennessee counties. The purpose of the fund is to help survivors who are fleeing violence or in the process of establishing new safe homes. Additionally, funds may be used to help survivors who have lost income due to COVID-19 or need help with rent, mortgage, hotel costs, and utilities. Only specific expenses are permitted by this fund.

Examples of Funding we CAN Provide:

Bus tickets
Utility deposits/payments
Rent deposits/payments

Examples of Funding we CANNOT Provide:

Money orders
Medications
Payments made directly to applicants

The Coalition accepts applications for emergency assistance from:

Domestic violence and sexual assault survivors
Advocates at shelters or programs who are assisting survivors

If you are a survivor who has not yet been in contact with a domestic violence shelter or rape crisis center, please let us know and we will connect you to the program in your area. The program can provide you with a full range of needed services, including assistance with establishing a safe and sustainable housing option.

Application Guidelines:

a) You or the advocate who is assisting you must provide a narrative description of your situation and the need for emergency financial assistance.

b) Priority will be given to applications that demonstrate financial need, safety concerns, and lack of local funding sources available to assist the applicant.

*Additionally, funds may be used to help survivors who have lost income due to COVID-19 or need help with rent, mortgage, hotel costs, and utilities.

c) Please attach supporting documentation for all rent and utility requests. The Coalition requires either a lease agreement, account contract, or current bill reflecting the requested need.

d) TN Coalition Emergency Assistance Fund is considered a fund of last resort and must be used as such. If you need help finding other financial assistance options, please give our office a call at (615) 386-9406. If you have already applied for assistance from other organizations, please list those on your application.

e) If you prefer to submit a paper application, the application can be found here. Please submit the downloadable application to emergencyassistance@tncoalition.org along with supporting documentation.

Funding and Reporting Procedures:

a) The Tennessee Coalition is sensitive to the emergent needs of survivors and aims to respond to applications within 1-2 days of submission. During periods when we receive a large number of applications, however, response times may be longer.

b) Payments cannot be made directly to applicants; they are made to vendors or to member programs that are working with survivors. Funds may be made available immediately, or may need to be submitted on a reimbursement basis depending on time constraints. Invoices and receipts will be needed for payment.

A Note About Greyhound Bus Ticket Requests:

If you need a Greyhound bus ticket, please submit the Emergency Financial Assistance application with an estimate of the ticket cost. Once you have received preliminary approval from the Tennessee Coalition, have your advocate at the shelter or domestic violence program purchase your ticket and we will reimburse the program for the cost of the ticket (a final ticket receipt must be provided).
If the program cannot purchase the bus ticket on your behalf, the program can request help with this process from the Tennessee Coalition.

Greyhound Bus Ticket Purchasing Tips:

Choose a bus itinerary in advance – this will expedite the ordering process.
Order the tickets online to be picked up at will call for the survivor.
Provide the survivor with a password to pick up the tickets at the ticket counter at least one hour prior to departure.
Passengers can carry on 1 bag and check up to 2 bags in the baggage compartment (the first checked bag is free, the second is $15).
Tickets are non-refundable.

Emergency Assistance Fund Application

Please fill out the form below as completely as possible and we will get in touch with you within one business day.
Are you or have you been a victim of domestic or sexual violence? (¿Eres o ha sido víctima de violencia doméstica o sexual?)*
- Yes, please proceed with the application (Sí, continúe con la solicitud.)
- No, if you are not a survivor of domestic or sexual violence, but are in need of resources related to COVID-19, please call The United Way Helpline at 2-1-1. (No, si no es un sobreviviente de violencia doméstica o sexual, pero necesita recursos relacionados con COVID-19, llame a la Línea de ayuda de United Way al 2-1-1)
I. CONTACT INFORMATION
Date (Fecha)
MM slash DD slash YYYY
Name (Nombre)*
First Last
Date of Birth (Fecha de Naciemento)*
MM slash DD slash YYYY
Safe Phone Number (Numero de contacto seguro)*
Email (Dirección de correo electrónico)*
Do you have an organization helping you complete this form? (¿Tiene una organización que le ayude a completar este formulario?)*
- Yes (Sí)
- No (No)
If so, please complete the next four questions. If no, skip to section II. (Si es así, complete las siguientes cuatro preguntas. Si no, pase a la sección II)
Name of Organization (Nombre de Organizacion)
Contact Person/Title (Persona de contacto y Titulo)
Email Address (Correo electronico de organizacion)
Office Telephone/Ext. (Numero de telefono de organizacion y extension)
II. DEMOGRAPHIC INFORMATION
Gender (Genero)
Age (Edad)
Race (Raza)
Location: Please check the county where you are currently located. (Cheque el condado donde está actualmente localizada(o))
East
- Anderson
- Bledsoe
- Blount
- Bradley
- Campbell
- Carter
- Claiborne
- Cocke
- Cumberland
- Grainger
- Greene
- Hamblen
- Hamilton
- Hancock
- Hawkins
- Jefferson
- Johnson
- Knox
- Loudon
- Marion
- McMinn
- Meigs
- Monroe
- Morgan
- Polk
- Rhea
- Roane
- Scott
- Sevier
- Sullivan
- Unicoi
- Union
- Washington
Middle
- Bedford
- Cannon
- Cheatham
- Clay
- Coffee
- Davidson
- DeKalb
- Dickson
- Fentress
- Franklin
- Giles
- Grundy
- Hickman
- Houston
- Humphreys
- Jackson
- Lawrence
- Lewis
- Lincoln
- Macon
- Marshall
- Maury
- Montgomery
- Moore
- Overton
- Perry
- Pickett
- Putnam
- Robertson
- Rutherford
- Sequatchie
- Smith
- Stewart
- Sumner
- Trousdale
- Van Buren
- Warren
- Wayne
- White
- Williamson
- Wilson
West
- Benton
- Carroll
- Chester
- Crockett
- Decatur
- Dyer
- Fayette
- Gibson
- Hardeman
- Hardin
- Haywood
- Henderson
- Henry
- Lake
- Lauderdale
- Madison
- McNairy
- Obion
- Shelby
- Tipton
- Weakley
- Robertson
Do you have any minor children in your care? If so, what are their ages? List ages separated by commas. (Tiene hijos menores de edad a su cuidado? Si es asi, cuales son las edades?)
What is your gross (before tax) annual household income? (Ingresos del hogares antes de impuestos)*
- Less than $15,000
- $15,000- $20,000
- $20,000- $25,000
- $25,000- $30,000
- $30,000- $35,000
- $35,000- $40,000
- $40,000- $45,000
- $45,000- $50,000
- $50,000 and above
III.
The TN Coalition Emergency Assistance Fund is considered a fund of last resort and must be used as such. If you need help finding other financial assistance options, please give our office a call at 615-386-9406. El fondo de asistencia para emergencias de La Coalición de Tennessee se considera un fondo de último recurso y debe utilizarse como tal. Si necesita ayuda para encontrar otras opciones de asistencia financiera, por favor llame a nuestra oficina al 615-386-9406.
If you have already applied for assistance from other organizations, please list those here: (Si ha solicitado la asistencia de otras organizaciones, sírvase indicarlas aquí:)
IV. REQUESTED AMOUNT (CANTIDAD SOLICITADA)
Requested Amount (Cantidad solicitada):*
V. REQUIRED DETAILS (DETALLES REQUERIDOS)
1. Are you a survivor of Domestic Violence/Sexual Assault? (Eres una sobreviviente de violencia doméstica / asalto sexual?)
- Yes
- No
2. Please provide a detailed description of your emergency needs (Detalle su necesidades de emergencia)*
3. Please provide cost estimates for the items or services that you need (Por favor indique los gastos estimados para los artículos o servicios que necesita):*
4. Please attach supporting documentation for all rent and utility requests. The Coalition requires either a lease agreement, account contract, or current bill reflecting the requested need with all such requests. (Por favor ajunte la documentación justificativa para la solicitud de la renta y utilidades. La Coalición requiere el acuerdo de arrendamiento, el contrato de cuenta, o un proyecto de ley corriente que refleje la necesidad solicitada con toda esa solicitud.)
Drop files here or

Max. file size: 2 GB.
VII. SAFETY EVALUATION (EVALUACION DE SEGURIDAD)
How this will help: (Como le ayudara)
1) With this assistance, I (the survivor) will be able to escape an abusive situation and feel(s) safer: (Con esta ayuda, yo (la/el sobreviviente) soy capaz de escapar del abuso y sentir me más segura/o).*
- Strongly disagree (Totalmente, no estoy de acuerdo)
- Disagree (No estoy de acuerdo)
- No opinion (No hay opinión)
- Agree (Estoy de acuerdo)
- Strongly Agree (Estoy totalmente de acuerdo)
2) With this assistance, I (the survivor) will be able to cover some of the expenses necessary to get safe (Con esta ayuda, Yo (la/el sobreviviente) voy a poder cubrir algunos de los gastos necesarios para estar segura/o)*
- Strongly disagree (Totalmente, no estoy de acuerdo)
- Disagree (No estoy de acuerdo)
- No opinion (No hay opinión)
- Agree (Estoy de acuerdo)
- Strongly agree (Estoy totalmente de acuerdo)
VIII. COVID-19 EVALUATION (COVID-19 EVALUACION)
1) Has COVID had a negative impact on you financially? (¿COVID ha impactado sus finanzas negativamente?*
- Yes (Si)
- No (No)
2) Has COVID made it harder to meet your basic needs (such as food and a home)? (COVID hizo que fuera mas difícil satisfacer sus necesidades básicas (como la comida en casa)?)*
- Yes (Si)
- No (No)
3) If you are experiencing abuse, has the abuse escalated/gotten worse during this time? (Si está sufriendo abuso, ¿el abuso ha aumentado o empeorado durante este tiempo?)*
- Yes (Si)
- No (No)
IMPACT NASHVILLE ASSISTANCE NETWORK
Shared Case Management Software - CharityTracker RELEASE OF INFORMATION (ROI)
The Impact Nashville Assistance Network, hereinafter referred to as "CharityTracker", is a shared, computerized record keeping system that captures information about people experiencing need for emergency services, including but not limited to assistance with utility bills, medications, rent/mortgage payments, etc. United Way of Greater Nashville (Administrating Agency) administers CharityTracker on behalf of participating agencies of the CharityTracker Assistance Network, including Tennessee Coalition to end DV and SV (Participating Agency).
Client's Name
First Middle Initial Last
Client's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Client's Date of Birth
MM slash DD slash YYYY
Client's SSN
Client's Phone Number
I understand that all information gathered about me is personal and private and that I do not have to participate in CharityTracker. I have had an opportunity to ask questions about CharityTracker and to review the basic identifying information, which is authorized by this release for the CharityTracker Assistance Network Participating Agencies to share. I also understand that information about non-confidential services provided to me by CharityTracker participating agencies may be shared with other CharityTracker Participating Agencies. This Release of Information will remain in effect for 3 years from the date noted under my signature at the bottom of this page unless I make a formal request to this Organization that I no longer wish to participate in CharityTracker. I also understand information entered in CharityTracker will be retained by the organization initiating this Release of Information.
I agree.
I understand that all information gathered about me is personal and private and that I do not have to participate in CharityTracker. I have had an opportunity to ask questions about CharityTracker and to review the basic identifying information, which is authorized by this release for the CharityTracker Assistance Network Participating Agencies to share. I also understand that information about non-confidential services provided to me by CharityTracker participating agencies may be shared with other CharityTracker Participating Agencies. This Release of Information will remain in effect for 3 years from the date noted under my signature at the bottom of this page unless I make a formal request to this Organization that I no longer wish to participate in CharityTracker. I also understand information entered in CharityTracker will be retained by the organization initiating this Release of Information.
Dependent's Name Relationship Date of Birth Social Security Number
I authorize Tennessee Coalition to end DV and SV, as a CharityTracker Participating Agency, to share my basic, identifying and non-confidential service transactions/information with other CharityTracker Participating Agencies. I also authorize Tennessee Coalition to end DV and SV, to share my previously provided basic identifying and non-confidential information, service transactions, financial assistance, and program goals from a third-party database with other agencies participating in CharityTracker. I authorize the use of a copy of this original to serve as an original for the purposes stated above. I further authorize Tennessee Coalition to end DV and SV (Participating Agency), as a CharityTracker Participating Agency, to share my dependent's basic, identifying and non-confidential service transactions/information with other CharityTracker participating agencies. I authorize Tennessee Coalition to end DV and SV to share my dependents' previously provided basic, identifying and non-confidential information, service transactions, financial assistance, and program goals from a third-party database with agencies participating in CharityTracker.
I agree.
I authorize Tennessee Coalition to end DV and SV, as a CharityTracker Participating Agency, to share my basic, identifying and non-confidential service transactions/information with other CharityTracker Participating Agencies. I also authorize Tennessee Coalition to end DV and SV, to share my previously provided basic identifying and non-confidential information, service transactions, financial assistance, and program goals from a third-party database with other agencies participating in CharityTracker. I authorize the use of a copy of this original to serve as an original for the purposes stated above. I further authorize Tennessee Coalition to end DV and SV (Participating Agency), as a CharityTracker Participating Agency, to share my dependent's basic, identifying and non-confidential service transactions/information with other CharityTracker participating agencies. I authorize Tennessee Coalition to end DV and SV to share my dependents' previously provided basic, identifying and non-confidential information, service transactions, financial assistance, and program goals from a third-party database with agencies participating in CharityTracker.
Client and/or Parent-Legal Guardian's Authorizing Signature
First Last
Date
MM slash DD slash YYYY
Agency Representative Signature
First Last
Date
MM slash DD slash YYYY
Consent
I agree.
Each party agrees that this Agreement and any other documents to be delivered in connection herewith may be electronically signed, and that any electronic signatures appearing on this Agreement or such other documents are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
Thank you for applying to the Tennessee Coalition to End Domestic and Sexual Violence For Emergency Financial Assistance! Gracias por aplicar para asistencia financiera de emergencia de la Coalición de Tennessee para acabar con la violencia doméstica y sexual.

Dependent's Name	Relationship	Date of Birth	Social Security Number

Emergency Financial Assistance Fund (EFA)

Please contact the agencies below for additional support and services:

Emergency Assistance Fund Application

Please fill out the form below as completely as possible and we will get in touch with you within one business day.

I. CONTACT INFORMATION

If so, please complete the next four questions. If no, skip to section II. (Si es así, complete las siguientes cuatro preguntas. Si no, pase a la sección II)

II. DEMOGRAPHIC INFORMATION

Location: Please check the county where you are currently located. (Cheque el condado donde está actualmente localizada(o))

III.

IV. REQUESTED AMOUNT (CANTIDAD SOLICITADA)

V. REQUIRED DETAILS (DETALLES REQUERIDOS)

VII. SAFETY EVALUATION (EVALUACION DE SEGURIDAD)

VIII. COVID-19 EVALUATION (COVID-19 EVALUACION)

IMPACT NASHVILLE ASSISTANCE NETWORK

Thank you for applying to the Tennessee Coalition to End Domestic and Sexual Violence For Emergency Financial Assistance! Gracias por aplicar para asistencia financiera de emergencia de la Coalición de Tennessee para acabar con la violencia doméstica y sexual.