Name *

First Name

Last Name

Are you a Black American *

Yes

No

Can you provide a photo of identification? *

Yes

No

Date Funds are Needed *

MM

DD

YYYY

Can you provide proof of outstanding bills, or other documentation of what the funds will be used for? *

Yes

No

Can you provide proof of who you are? *

i.e. Video of yourself explaining who you are and what you are needing. This video is for me (I will never share publicly) to properly vet every person asking for assistance.

Yes

No