This is the first step in the loan inquiry process and does not constitute a full loan application. A Fountain Fund staff member will contact you about your inquiry. Name* First Last Date of Birth* MM DD YYYY Address*If currently incarcerated, provide address upon release. Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email Purpose of Loan*Amount of Loan*Have you ever been incarcerated?*YesNoDate of most recent release from incarceration?* MM DD YYYY Are you a US citizen?*YesNoSource of Income*EmployedSocial Security We're Sorry We are only able to offer loans to former incarcerated individuals who are US citizens. If you have any questions regarding our program please contact us.