Gradient Gives Back | Application

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Apply or nominate a deserving family today.

Application will be accepted nationwide through November 1, 2012.

PART 1) – PERSONAL INFORMATION

Name

Home Address

Street
City
State
Zip
County

Mailing Address (if different)

Street
City
State
Zip
County

Contact Information

Home Phone
Work Phone
Cell Phone
Email Address:

Military Information

Did you serve in the military, and if so, which branch?

If yes, did you receive an honorable discharge from the military?

Family Information

Marital Status

If married, how many years?

List all members currently living in the household (including yourself):

Age Name DOBRelationship Employed/Job/Education

**IMPORTANT**
Have ANY members of the household ever been convicted of or been charged with a crime? (It could be as simple as a misdemeanor driving violation or as serious as armed robbery.) We do extensive background checks.

If yes, please describe (include dates):

Has the family or anyone in the family been involved in a lawsuit?

If yes, please describe state and county where filed, parties involved, and the nature of the dispute, (include dates):

Have any members of the household been on television?

If yes, please describe (include dates):

Does anyone in the household have a MySpace page, Facebook, blog or Web site of any kind?

If yes, please list all of the addresses:

Please describe what kind of volunteer work or community service you and/or your family has been involved in:

Your and/or your family's proudest achievements and/or recognitions by the community?

Please list make, model and year of all cars owned by household:

If selected, will W2s and/or tax returns for the last two years be available? (Please do not include them now.)

If not, why?

IF YOU ARE NOMINATING SOMEONE, PLEASE INCLUDE YOUR INFORMATION:

Your Name
Street Address
City
State
Zip
County

Contact Information

Home Phone
Work Phone
Cell Phone
Email Address:

PART 2) – YOUR STORY (Mandatory)

Please summarize the family's CURRENT situation. What makes them deserving? What makes the situation unique? (Help us. Be concise.)

PART 3) – FINANCIAL SITUATION

Household Income:

Approximate net worth? (excluding your principal)

Savings and/or Retirement Accounts: (check all that apply)

Checking
Savings
CDs
Life Insurance
Annuities
IRA/Roth IRA
401(k) or 403(b)
Pension
Other

Insurance: (Check all that apply)

Health Insurance
Life Insurance
Long-Term Care Insurance
Home Insurance
Auto Insurance

Home ownership?

If yes, how much is owed as of today?

What are the monthly mortgage/lease payments?

If yes, are the mortgage payments current?

If not, why?

Other properties?

If yes, what type of property?

Receiving state aid for foster care, disability, adoption subsidy or any other benefits of this kind?

If yes, how much and for whom?

Recipient Amount

Approximate monthly debt?

Loan/credit card nameBalanceInterest rateMin monthly payment

Current on loans/debts?

If not, why?

Employer’s name and phone number:

NamePhone

Agree to Terms?

By submitting this application and agreeing to the terms, you waive any rights to all materials provided to Gradient, and further acknowledge the requirement of executing such other additional releases and authorizations as required by Gradient, in their sole discretion, in conjunction with your application for participation in the ‘Gradient Gives Back’ program.

Your personal information will not be sold, or shared with unaffiliated third parties except as necessary to maintain and process information or when the law requires it.