Request for Assistance

First Name ______________________________        Last Name ______________________________ 

Street Address_______________________________________________________________________

City____________________________________  State _____________  Zip Code_________________

Phone ___________________ Fax____________________ E-Mail _____________________________

Employer Name ______________________________________________________________________

Employer Address ____________________________________________________________________

City _____________________________________  State ______________  Zip Code _____________

Work Telephone ____________________________________ Years with this company ____________

Supervisor Name _____________________________  Supervisor telephone______________________

Current Gross Income ______________________________ annually / monthly (circle one that applies)

Personal Reference:________________________________ Relationship: ________________________

Reference Phone: _________________________ Reference email: _____________________________

Number of children ______

Names/ages of children

____________________

____________________

____________________

____________________

____________________

____________________

Type of Assistance Needed:

Child Care: __________________________________________________________________________

Medical expenses: ____________________________________________________________________

Mortgage/Rent: ______________________________________________________________________

Utilities: ____________________________________________________________________________

Food: ______________________________________________________________________________

Clothing: ___________________________________________________________________________

Career Counseling: ___________________________________________________________________

Auto Repairs: _______________________________________________________________________

Other:  _____________________________________________________________________________

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