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Maternity Savings Program Application

Maternity Leave Match Savings Fund

Applicants must have bills in their name, be pregnant, live in Douglas County and have a source of income. The applications will be reviewed as received. Please allow up to 15 business days for review and processing of applications. Applications must be filled out completely to be considered. Questions: Call or text Rachel Kocol at 402‐709‐2659. 

 

To download the PDF version of this application click here: 


General Information:
First Name
Last Name
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Country
Address Line 1
City
State
Postal Code

Gender

Race: Please check all that apply
Other:

Background Information:
How far into your pregnancy are you?
What is your due date?
How many children do you currently have? (not including your current pregnancy)
How long are you planning on being on maternity leave?
What is your current living situation?
Other:
Is this living situation one you will remain in for at least 6 months?
Do you have a lease in your name?

Financial Information:
Are you getting assistance from other programs or resources in the metro area?
If yes, please explain where:
Are you currently employed?
If yes, where are you working?
How many hours do you work in one week?
Are you able to save money for this program?
Are you currently enrolled in school? (GED, high school, college, etc.)
If yes, what school are you attending?

Support System:
Is your child’s father going to be involved moving forward?
Do you have people you can rely on in time of need?
If yes, please explain:

Current Monthly Budget:

FIXED EXPENSES

Rent
Utilities
Cell Phone
Internet
Car Payment/Lease
Gasoline/Bus Tickets
Car Insurance
Child Care
Groceries

 

 

Total Monthly Income:
Total Monthly Expenses:
Money left over each month:

Questions related to program:
Are you willing to work with some type of coach or supportive person?
Are you willing to take a prenatal or newborn class?
Are you willing to participate in a post assessment?

What bills are currently in your name?

How would this program be beneficial to you?

 

Please remember you will be required to prove that you saved the money before being matched ‐ this will be done by providing a bank statement to Project Everlast. Fill this form out to the best of your ability and knowledge before turning it in.


I certify all information on this application is true, complete, and accurate. I understand any information given falsely or withheld may make me ineligible for consideration or award. I understand that funds must be used for the purpose stated on this application and that I will be required to submit proof of purchase. I also understand that money received through the Maternity Savings Program is considered income by the IRS and must be reported for tax purposes.

 

Applicant Signature
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Date