LEAP Application - Medical/Financial Crisis

We are so sorry you're experiencing a crisis, and we are here to help! Please fill out this application as completely and accurately as possible to determine if you qualify for LEAP emergency assistance.

If you have any questions about LEAP or need assistance with your application, please contact Heather Johnson, LEAP Administrator, at 803-821-1288 or hyjohnson@lexington1.net.

Your Contact Information

Prefix (Mr., Mrs., Ms., Dr., etc.)

First Name *

Last Name *

Email *

Address Line 1 *

Address Line 2

Phone *

City *

State *

Zip *

Lexington One Connection * The field Lexington One Connection is required.

Work Site or School * The field Work Site or School is required.

School Year

Immediate Household

Please list all individuals who are permanent residents of the home, including yourself, spouse/significant other, children, etc.

Individual 1 Name * The field Individual 1 Name is required.

Individual 1 Relationship to Applicant

Individual 2 Name The maximum length for the field Individual 2 Name is 500 characters.

Individual 2 Relationship to Applicant

Individual 2 School & Grade (if child) The maximum length for the field Individual 2 School & Grade (if child) is 500 characters.

Individual 3 Name The maximum length for the field Individual 3 Name is 500 characters.

Individual 3 Relationship to Applicant

Individual 3 School & Grade (if child) The maximum length for the field Individual 3 School & Grade (if child) is 500 characters.

Individual 4 Name The maximum length for the field Individual 4 Name is 500 characters.

Individual 4 Relationship to Applicant

Individual 4 School & Grade (if child) The maximum length for the field Individual 4 School & Grade (if child) is 500 characters.

Individual 5 Name The maximum length for the field Individual 5 Name is 500 characters.

Individual 5 Relationship to Applicant

Individual 5 School & Grade (if child) The maximum length for the field Individual 5 School & Grade (if child) is 500 characters.

Individual 6 Name The maximum length for the field Individual 6 Name is 500 characters.

Individual 6 Relationship to Applicant

Individual 6 School & Grade (if child) The maximum length for the field Individual 6 School & Grade (if child) is 500 characters.

List anyone else not included above The maximum length for the field List anyone else not included above is 5000 characters.

Crisis Description

Please describe the crisis you experienced in detail, including specific dates of the event(s) that led to the crisis. For example: the date your employment status changed and why; the date your household income changed and why; the date you received a medical diagnosis and/or treatments; the date you started leave without pay status; the date you anticipate returning to work.

Description of Crisis * The field Description of Crisis is required.

How did this crisis impact or disrupt your financial situation? * The field How did this crisis impact or disrupt your financial situation? is required.

Monthly Household Income

Please enter the actual amount for each item below. Enter 0 if it does not apply to your situation.

Applicant Monthly Net Earned Income * The numeric field Applicant Monthly Net Earned Income is required.

Spouse/Other Monthly Net Earned Income * The numeric field Spouse/Other Monthly Net Earned Income is required.

Additional Net Earned Income * The numeric field Additional Net Earned Income is required.

Social Security Payments * The numeric field Social Security Payments is required.

Retirement Benefits * The numeric field Retirement Benefits is required.

SNAP (Food Stamps) * The numeric field SNAP (Food Stamps) is required.

WIC Supplemental Nutrition * The numeric field WIC Supplemental Nutrition is required.

TANF (Temporary Assistance for Needy Families) * The numeric field TANF (Temporary Assistance for Needy Families) is required.

Unemployment * The numeric field Unemployment is required.

Short- or Long-term Disability * The numeric field Short- or Long-term Disability is required.

Workers’ Compensation * The numeric field Workers’ Compensation is required.

HUD - Housing * The numeric field HUD - Housing is required.

HUD - Utilities * The numeric field HUD - Utilities is required.

ABC Vouchers for Childcare * The numeric field ABC Vouchers for Childcare is required.

Child Support/Alimony * The numeric field Child Support/Alimony is required.

Family Assistance * The numeric field Family Assistance is required.

Agency/Church Assistance * The numeric field Agency/Church Assistance is required.

Any Other Income Not Listed Above * The numeric field Any Other Income Not Listed Above is required.

Please provide any relevant details, notes, or other information about your monthly income. The maximum length for the field Please provide any relevant details, notes, or other information about your monthly income. is 5000 characters.

Monthly Household Expenses

Please enter the actual amount for each item below. Enter 0 if it does not apply to your situation.

Rent/Mortgage * The numeric field Rent/Mortgage is required.

Rental/Home Insurance * The numeric field Rental/Home Insurance is required.

Food * The numeric field Food is required.

Phone (Mobile and Landline) * The numeric field Phone (Mobile and Landline) is required.

Internet * The numeric field Internet is required.

Cable/Streaming Services * The numeric field Cable/Streaming Services is required.

Water/Sewer * The numeric field Water/Sewer is required.

Electricity * The numeric field Electricity is required.

Propane * The numeric field Propane is required.

Credit Cards * The numeric field Credit Cards is required.

Personal/Title/Payday Loans * The numeric field Personal/Title/Payday Loans is required.

Student Loans * The numeric field Student Loans is required.

Car Payment(s) * The numeric field Car Payment(s) is required.

Car Insurance * The numeric field Car Insurance is required.

Gas * The numeric field Gas is required.

Clothing/Shoes * The numeric field Clothing/Shoes is required.

Childcare * The numeric field Childcare is required.

Child Support/Alimony Payments * The numeric field Child Support/Alimony Payments is required.

Nonfood Necessities (toiletries, laundry, etc.) * The numeric field Nonfood Necessities (toiletries, laundry, etc.) is required.

Prescriptions & Out-of-Pocket Healthcare * The numeric field Prescriptions & Out-of-Pocket Healthcare is required.

Any Other Expenses Not Listed Above * The numeric field Any Other Expenses Not Listed Above is required.

Please provide any relevant details, notes, or other information about your monthly expenses. The maximum length for the field Please provide any relevant details, notes, or other information about your monthly expenses. is 5000 characters.

Assistance Requested

Please provide the vendor/company name and amount for each item with which you are requesting assistance. You must provide a copy of each bill to the LEAP Administrator after submitting your application. Leave blank if you are not requesting assistance in that category. There are funding caps on assistance; please check the "How LEAP Helps" section of the LEAP website for the most current information.

Housing Vendor The maximum length for the field Housing Vendor is 500 characters.

Housing Amount The field Housing Amount must be a number.

Electricity Vendor The maximum length for the field Electricity Vendor is 500 characters.

Electricity Amount The field Electricity Amount must be a number.

Propane/Gas Vendor The maximum length for the field Propane/Gas Vendor is 500 characters.

Propane/Gas Amount The field Propane/Gas Amount must be a number.

Water Vendor The maximum length for the field Water Vendor is 500 characters.

Water Amount The field Water Amount must be a number.

Sewer Vendor The maximum length for the field Sewer Vendor is 500 characters.

Sewer Amount The field Sewer Amount must be a number.

Medical Care Vendor The maximum length for the field Medical Care Vendor is 500 characters.

Medical Care Amount The field Medical Care Amount must be a number.

Would you like to request a grocery gift card? * The field Would you like to request a grocery gift card? is required.

How many people are in your household? * The numeric field How many people are in your household? is required.

Please list any additional assistance you are requesting, including vendor and amount. The maximum length for the field Please list any additional assistance you are requesting, including vendor and amount. is 5000 characters.

Authorization to Share Anonymous Information

With your permission, LEAP administrators may share an anonymous summary of your application to show the impact of contributions to the program. Your personal details will never be shared. Your response to this question will not affect the outcome of your application in any way.

I consent to LEAP sharing my story anonymously * The field I consent to LEAP sharing my story anonymously is required.

Signature

By providing my electronic signature below, I certify that all information in this application is true, accurate, and complete to the best of my knowledge. I am requesting emergency financial assistance due to an unforeseen event that has created a financial hardship for my household. I authorize the request and release of personal information to the Foundation’s LEAP Administrator by any vendors, utilities, landlords, employers, medical providers, and/or any other entity to whom LEAP may make a payment on my behalf. The LEAP Administrator has my permission to verify information that I have supplied to aid in the completion of my application for assistance.

Electronic Signature (Full Name) * The field Electronic Signature (Full Name) is required.

Review and Submit

By submitting this application, you agree:

All information in this application is complete and accurate to the best of your ability.
Your application must be reviewed by a committee of Lexington One employees to determine eligibility. Your name and contact information will be removed, but all other information included in your application will be shared with the review committee members. They will keep your information confidential and will not discuss or share any information about your application with anyone except authorized LEAP administrators and review committee members.
Submitting an application does not guarantee approval or assistance.
You are required to submit supporting documentation by email (info@lex1edfound.org), mail or dropoff (702 North Lake Drive, Lexington SC 29072), or interoffice mail (LEAP - Educational Foundation).