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how to request help

Qualifications for consideration into our Gift Program is based on the following criteria:

- Lost income or in the process of losing income -

- In the process of being evicted from home or rental property in the upcoming 90 days -

apply today to get help

It is important for constituents to work and maintain a job in order to sustain a new life forward.

First Name

Middle Initial

Last Name

Current Address

City

State

Zip Code

Phone

Cell Phone

Date of Birth

Gender

ID or License #/ expiration date (provide copy)

SSN (provide copy)

Additional Information (Seniors/Military/etc.)

Availability for Follow-ups

Any additional: health problems/disabilities

Referred by

Have you lost your job in the last 90 days?

Yes

Are you in the process of being evicted?

Yes

Do you have any substance abuse issues we should know about?

Yes

Moved 2 or more times due to economic challenges?

Yes

Live in a RV, hotel or motel and looking for permanent housing?

Yes

How many people in household (adults and children)?

Current Source of Income?

Amount per hour or month (if salary)?

How long you’ve been there?

Full time, Part time, or volunteer (if volunteer, how many hours a week)?

Supervisor Name

Supervisor Phone

Supervisor Email

Company Name

Company Phone

Company Address

Any other source of income/assistance?

Yes

Company Name

Company Phone

Company Address

Supervisor Name

Supervisor Phone

Supervisor Email

Please provide information of the help you are seeking:

Resume Building /Job seeking

Home/Apartment Assistance

Financial Training

Food/Hygiene Supplies

Resources on Forms

Other

Resouces on Forms

Please specify

Other

Please specify

ELECTRONIC SIGNATURE AGREEMENT

I affirm and certify that all the information and answers to questions herein are complete, true and correct to the best of my knowledge and belief. I understand that any misrepresentation, falsification, or omission of any facts called for in the application may render this application void and will be cause for termination of any subsequent benefits, whenever discovered.

By selecting the "I Accept" button, I am signing this application electronically. I agree my electronic signature is the legal equivalent of my manual signature on this application.

I accept terms & conditions

thanks for submitting!

pay it forward

If you have ever been in a situation where you needed an extra hand or little help to move you forward in life...do the same for someone else and pay it forward. Kindness is always repaid many times over.

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