Are You Eligible To Apply | Jack's Family Fund

Name*

First Last

Preferred Phone Number

Email*

Enter Email Confirm Email

Address

Street Address Address Line 2 City State ZIP Code

Do you live or work in a community where we operate a Jack's Family Restaurant?*

Jack's Family Restaurant is a regional chain that operates primarily in Alabama (north of I-10). We also have a few restaurants in Mississippi, Tennessee, and Georgia. To find your closest Jack's visit Find a Jack's

Yes
No

We are sorry you are going through a difficult time. However, we only offer assistance to those who live or work in a community where we operate a Jack's Family Restaurant. Therefore, you are not eligible to apply. To find other community resources, please contact your local 2-1-1 service or visit 211.org

Are you seeking a contribution toward your loved one's funeral/burial?*

Yes
No

Have you received an assistance grant from us in the last 12 months?*

yes
no

We are sorry you are going through a difficult time. Assistance grants are limited to one award per 12-month time frame (based on the date the grant was awarded.) For example, if you previously applied on 10/15/23 and assistance was granted on 11/2/23, you will not be eligible for consideration again until 11/2/24.

Is your current need the direct result of one of these hardships:*

Mark the hardship category that directly led to your emergency financial need.

illness/injury
accident
natural disaster/ storm
death
crime
fire
sudden, unexpected loss of housing
none of these - more details provided below

Additional Comments*

Please use the space below to explain the situation that led to you needing emergency financial assistance. For example: Don't just say you need help with your bill because it's about to be disconnected. Tell us what caused you to fall behind on your bill to begin with.

Prior to this hardship, were you able to afford all of your essential living expenses?*

Essential living expenses include housing, utilities, groceries, and medical care.

Yes
No

Will you be self-supporting (able to stay current with all your bills) moving forward?*

Essential living expenses include housing, utilities, groceries, and medical care.

Yes
No

Are you currently employed?*

If you are on FMLA or have signed an offer letter confirming start date and pay rate, please answer "yes".

Yes
No

Employer*

Mark any of the following you receive*

Food stamps/ WIC
TANF
Social Security/Disability
Short-term disability benefits (paid FMLA)
None

What is your emergency financial need?*

Please mark what you need assistance with

rent/mortgage
utilities (electric, water, natural gas)
funeral
groceries & personal care items
life-saving medical (prescriptions, treatments, procedures) or medical debt facing collections
temporary, emergency shelter
other

You marked "other" as your financial need. Please explain.*

Are you currently (or will you be within the next 30 days) without access to any of the following:? Which ones?

Mark all that apply

housing/shelter
running water
electricity
heat
2 or more nutritious meals per day
basic clothing and personal care items
essential medical treatment/ procedure
none of these

Screening Evaluation