Assistance Request

Request for Assistance Form

Please be sure to complete all fields that are applicable to evaluating and confirming need.

Name

Street Address

Mailing Address

Phone

How long have you lived at this address?

Landlord's Name

Landlord's Phone Number

Total Number of household members

Household Member's Name and Relationship to You

Are you currently employed?

Yes No

If yes, where?

If you are not employed, why not?

If not employed, how long have you been unemployed?

Are you currently looking for work?

Yes No

If not, why?

Is anyone in your household employed at this time?

Yes No

If yes, where?

Are you receiving aid, financial or otherwise, such as unemployment insurance, social security, welfare, SNAP, or worker's compensation?

Yes No

Who referred you to us?

What is your need? Please be specific and provide documentation where needed.

Who has helped you in the past?

What did they do for you?

Have you contacted anyone else with your current need?

Yes No

If yes, who?

Whom may we contact to verify your need? If we can not contact individuals to confirm your need, we may not be able to assist you.

Relationship

Phone

Address

Final Instructions

Please provide a current form of picture identification, such as a driver's license. In addition, upload supporting documentation that confirms your need.

_____________

Please remember, our church is not a government-assisted agency. Our funds and resources are limited and are a result of direct donations from our congregation.

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By submitting this form, you grant us permission to evaluate and advocate as needed using any information provided in this Request for Assistance Form.

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