Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Date of Birth
Name & Age of Others in the Household
Marital Status (married, single, divorced)
Employment and Employer Contact Information for Verification
List other agencies/organizations you've contacted for this need
Church Affiliation
How did you hear about Love INC
Have you contacted Love INC before? If yes, please provide date.
How can we help you? Specific Request for Assistance
If requesting rent, please provide amount including name, address, phone number, and email of landlord
If requesting utility payment, please provide amount including name of utility company and account number
Any other needs that we can help with (clothing, food, furniture, etc.)
** Financial assistance is limited to those that RESIDE in Medina County ONLY. **
United Way Financial Empowerment participation may be REQUIRED prior to financial assistance
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