Apply or nominate a deserving family today.

PART 1) – PERSONAL INFORMATION


Home Address






Mailing Address (if different)







Contact Information







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





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
























**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.





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






Have any members of the household been on television?





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
















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







IF YOU ARE NOMINATING SOMEONE, PLEASE INCLUDE YOUR INFORMATION:








Contact Information








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





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












Insurance: (Check all that apply)





Home ownership?







If yes, are the mortgage payments current?





Other properties?





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



If yes, how much and for whom?




























Current on loans/debts?






Employer’s name and phone number:














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.