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Are You Eligible To Apply

Note: Please do not complete the evaluation multiple times trying to make it approve you. Doing so triggers a red flag in the system that will prevent your application from being considered.

Screening Evaluation

Please answer these questions to determine if your situation fits within our basic funding guidelines

Name*
First Last
Preferred Phone Number
Email*
Enter Email Confirm Email
Address
Street Address Address Line 2 City State ZIP Code
Do you live or work in a community where we operate a Jack's Family Restaurant?*
Jack's Family Restaurant is a regional chain that operates primarily in Alabama (north of I-10). We also have a few restaurants in Mississippi, Tennessee, and Georgia. To find your closest Jack's visit Find a Jack's
- Yes
- No
We are sorry you are going through a difficult time. However, we only offer assistance to those who live or work in a community where we operate a Jack's Family Restaurant. Therefore, you are not eligible to apply. To find other community resources, please contact your local 2-1-1 service or visit 211.org
Are you seeking a contribution toward your loved one's funeral/burial?*
- Yes
- No
Have you received an assistance grant from us in the last 12 months?*
- yes
- no
We are sorry you are going through a difficult time. Assistance grants are limited to one award per 12-month time frame (based on the date the grant was awarded.) For example, if you previously applied on 10/15/23 and assistance was granted on 11/2/23, you will not be eligible for consideration again until 11/2/24.
Is your current need the direct result of one of these hardships:*
Mark the hardship category that directly led to your emergency financial need.
- illness/injury
- accident
- natural disaster/ storm
- death
- crime
- fire
- none of these - more details provided below
Additional Comments*
Please use the space below to explain the situation that caused you to fall behind on bills.
Prior to this hardship, were you able to afford all of your essential living expenses?*
Essential living expenses include housing, utilities, groceries, and medical care.
- Yes
- No
Will you be self-supporting (able to stay current with all your bills) moving forward?*
Essential living expenses include housing, utilities, groceries, and medical care.
- Yes
- No
Are you currently employed?*
- Yes
- No
Mark any of the following you receive*
- Food stamps/ WIC
- TANF
- Social Security/Disability
- None
Is your need an expense for which we offer assistance?*
rent/mortgage, utilities, funeral, groceries/ personal care, life-saving medical, temporary/emergency shelter
- Yes
- No
What is your emergency financial need?*
Please mark what you need assistance with
- rent/mortgage
- utilities (electric, water, natural gas)
- funeral
- groceries & personal care items
- life-saving medical (prescriptions, treatments, procedures) or medical debt facing collections
- temporary, emergency shelter
- other
You marked "other" as your financial need. Please explain.*
Are you currently (or will you be within the next 30 days) without access to any of the following:? Which ones?
Mark all that apply
- housing/shelter
- running water
- electricity
- heat
- 2 or more nutritious meals per day
- basic clothing and personal care items
- essential medical treatment/ procedure
- none of these

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124 West Oxmoor Road
Birmingham, AL 35209
United States

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