New Family Application

Please fill out the following information to apply for assistance from Miry's List.

Name *
Name
Date of Birth
Date of Birth
Phone
Phone
Address
Address
Spouse's Name
Spouse's Name
Spouse's Date of Birth
Spouse's Date of Birth
Spouse's Phone
Spouse's Phone
Date of Arrival in United States
Date of Arrival in United States
Immigration Status
Employer Address
Employer Address
Employer Phone
Employer Phone
$
Employer Address
Employer Address
Employer Phone
Employer Phone
$
$
1. The Family represents and warrants that it arrived to the United States under Refugee or Asylum status, pursuant to applicable United States Code, including but not limited to 8 USC § 1157 and 8 USC § 1158, as amended. (Please type your initials below to agree with this statement.)
2. The Family represents and warrants that it arrived to the United States within three years prior to the Execution date of this application. (Please type your initials below to agree with this statement.)
3. The Family represents and warrants that its current gross income is no more than 200% of the Federal Poverty Level for the current year (see bottom of page for calculation) (Please type your initials below to agree with this statement.)
4. The Family represents and warrants that it is in good standing with any and all applicable governmental authorities, regulatory bodies, and other governing organizations, and further, that the Family shall maintain good standing at all times hereunder. (Please type your initials below to agree with this statement.)
5. The Family agrees to provide Miry’s List with copies of any and all documentation supporting Acknowledgments 1 - 4, as requested. (Please type your initials below to agree with this statement.)
I certify that the information provided in this application is true and correct to the best of my knowledge. I understand that, if accepted into the Miry’s List program, falsified statements on this application will be considered grounds for termination.
I certify that the information provided in this application is true and correct to the best of my knowledge. I understand that, if accepted into the Miry’s List program, falsified statements on this application will be considered grounds for termination.
Today's Date
Today's Date

2018 POVERTY GUIDELINES
FOR THE 48 CONTIGUOUS STATES AND THE DISTRICT OF COLUMBIA
(ANNUAL INCOME)
 


POVERTY GUIDELINE


$12,140

$16,460

$20,780

$25,100

$29,420

$33,740

$38,060

$42,380


PERSONS IN FAMILY/HOUSEHOLD


1

2

3

4

5

6

7

8


For families/households with more than 8 persons, add $4,320 for each additional person.