SOLO MOM’s BENEVOLENCE REQUEST FORM
*Please read the guidelines provided and know that this request will be kept CONFIDENTAL*
PERSONAL INFORMATION
Last Name
:
First Name
:
Last Name:
*
First Name:
*
Address:
Apt #:
Address:
*
Apt #:
City:
*
State:
Zip:
State:
*
Zip:
*
Phone numbers:
Mobile:
Work:
Home:
Age:
Age:
*
Are you disabled?
*
Yes
No
Are you a member of Pine Grove?
*
Yes
No
If no, please indicate church affiliation:
Are you employed?
*
Yes
No
If no, how long have you been unemployed?
Are you currently seeking employment?
*
Yes
No
Purpose of Request
*
Food
Clothing
Financial
Other
If financial, please specify amount:
Please explain reason for financial request:
Have you received assistance from SOLO MOM’s in the past?
*
Yes
No
CHILD’S INFORMATION (If clothing is requested, please complete this section):
Gender
Age
Clothing Size
Shoe Size
FOR OFFICE USE ONLY
Chair/Co Chair Initials:
Financial Amount Approved:
Not Approved:
Date Processed:
/
Month
/
Day
Year
Date
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