Basic Information

Please confirm the following.

1) Are you a US resident and at least 18 years old?

Yes No

2) Do you currently have a regular source of income?

Yes No

3) Do you have a checking or savings account?

Yes No

4) Do you receive regular income or payments, such as SSI, SSDI, or paychecks?

Yes No

5) How would you describe your credit history?

Your Information

All fields on this step are required. Phone verification is required to continue.

First Name*

Last Name*

Email Address*

Address*

City*

State*

ZIP Code*

Mobile Number (10 digits)*

Enter your number, then click “Send Verification Text”.

Your Request

How much do you need to cover today? (Min $100 – Max $99,999)

Requested Amount*

Enter a number only (example: 1500)

Request Details

What will the funds be used for?*

When do you need the funds?*

Optional Support Information

These are optional and not required to continue.

Protection Options

Would you like to receive information later about protection options—such as life insurance or supplemental coverage (accident, critical illness, disability)—that may help protect your loved one?

Yes, you may contact me later No, not at this time

Legal Support Information

Would you like to receive information later about legal support options, such as criminal defense resources, that may be available to you or your loved one?

Yes, send me information later No, not at this time

Referral Information

How did you hear about us?*

This helps us route your request correctly.

Consent

All three consent boxes are required to continue.

Required: I consent to receive electronic disclosures and communications related to my request. I authorize Family First to use my information to match me with available options from third-party providers and to share my application status with the partner or service provider who referred me. Required: By selecting this checkbox, I consent to receive text messages from Family First regarding services that may be available to me. Messages may be sent using automated technology. To opt out, reply STOP. For help, reply HELP. Message and data rates may apply. Required: I agree to the Terms of Service and Privacy Policy and acknowledge that I have read them.

By continuing, you acknowledge the Terms and Privacy Policy available below.

Start Payment Assistance Request