In-Take Form

Home
About Us
- What We Do
- Volunteer
Get Help
Projects
Donor Dashboard

Home
About Us
- What We Do
- Volunteer
Get Help
Projects
Donor Dashboard

Request Support (Confidential Intake Form)

Hibah Hope Relief Foundation provides assistance based on need and available funds. Please complete this form as accurately as possible so we can review your request quickly and fairly.

Your Privacy Matters

We understand this information is personal. Everything you share is treated as confidential and used only to assess and process your request for support.

Privacy & Protection

Privacy Notice: The information you provide is encrypted when submitted and is only viewed by authorized Hibah Hope Relief team members involved in reviewing and processing requests. We do not sell or share your personal information. We only share limited details with a third party (such as a landlord, utility company, or service provider) when it’s necessary to arrange payment or confirm a bill, and only with your consent.

Name *

First

Last

Phone

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Household size (# people) *

Children under 18 (#) *

Proof of Need *

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Applicants may provide one or more documents to support the request. Equivalent documents are acceptable. • Rent arrears notice, eviction notice, or letter from landlord • Utility bill showing past-due amount or disconnection notice • Invoice/estimate for essential repairs related to basic living conditions • Pharmacy receipt or medical supply invoice (non-covered essentials) • Childcare invoice where needed to maintain employment • Transportation receipt/estimate for essential medical appointments • Bank statement excerpts showing insufficient funds (redact unrelated details if possible) • Pay stub / Record of Employment / benefit statement (EI/ODSP/OW) (optional) • Funeral home invoice/estimate for basic services (if applicable) • Letter from a community agency confirming hardship (optional)

Current employment status *

Unemployed
E.I / Government Assistance
Employed
Student
Disability
Other

Please provide job role, company, salary and how long you have been employeed *

How Urgent Do You Need The Funds? *

Immediate (0–48h)
Within 7 days
Within 30 days

Amount Requested *

Requested Assistance (check all that apply) *

Children of employeed

If Other Please Explain

Additional details (optional)

Do You Have Vendor Information ? *

Vendor Information

Vendor Payee/Name *

Phone

Website / URL

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Invoice #

Estimate amount (if applicable)

Please upload invoice/receipt/bill or proof of purchase

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Signature *

Clear Signature

By signing, I confirm the information provided is true to the best of my knowledge. I understand Hibah Hope Relief Foundation may request supporting documents to verify need. I consent to the collection and use of my information to assess eligibility, deliver assistance, and maintain required records.

Custom Captcha *

Want to make a difference?

Help us raise money for Canadians who need help

Donate

Emergency microgrants for Canadian families facing urgent hardship.

Instagram Whatsapp

What We Do

Hibah Hope Relief Foundation provides emergency microgrants to support Canadian families
Privacy Policy
By- Laws
Blog

Name *

First

Last

Email *

Name Email Signature

Signature *

Clear Signature

Consent to be added to our newsletter

Name

In-take Form