Assistance Request Form

Assistance Request Form

Fenton Area Resource and Referral welcomes all applications for assistance. By filling out this form, I understand that my information may be shared with the partners of FARR. All information provided will be kept confidential and used only in regards to my need/request for assistance.
Today's Date

MonthDayYear
Date
Instructions:

Once you have completed this application to the best of your ability, please contact FARR (810)-750-6244 for an appointment.
First Name
Last Name
Spouse/S.O. First Name
Spouse/S.O. Last Name
Referring Church/Organization
(How did you hear about FARR)
Have you ever received assistance from FARR or other local churches or agencies?

YesNoOther
Street Address
Street Address (Line 2)
City
State
ZIP
Country
How long have you lived here?
Do you have children?
(Names and ages)
If yes, what schools do your children attend?
Home Number
Please enter a valid phone number.
Cell Number
Please enter a valid phone number.
Email
example@example.com
Social Security Number
(Last 4 digits)
Birthdate

MonthDayYear
Date
Are you a United States veteran?

YesNo
Marital Status

SingleMarriedWidowedDivorcedPartnered
Do you belong to or attend a church or faith community?

YesNo
If yes, name of community:
Describe in detail your IMMEDIATE NEED:
Need contact info and account number:
Do you see your circumstances as temporary or long-term? Why?
Are you or your spouse/signifigant other employed? (No/Yes) Where? How long?
What ways have you searched for other resources to meet need? (Family, saving, selling items)
List all churches/agencies you have contacted/are receiving help from to meet your needs:
How have you taken action to reduce unnecessary expenses? (Eliminating cable bills, dining out?)
What other challenges are you and/or family facing at this time?
Emergency Contact Information
First Name (E.C.)
Last Name (E.C.)
Phone Number (E.C.)
Please enter a valid phone number.
Relationship

Household Income

	First and Last Name (including applicant and children)	Age	Relationship to Applicant	Monthly Income
1
2
3
4
5

Household Income

Please indicate all household members including applicant and children.

Household Member (1)
First and Last Name (including applicant and children) (1)
Age (1)
Relationship to Applicant (1)
Monthly Income (1)

Household Member (2)
First and Last Name (including applicant and children) (2)
Age (2)
Relationship to Applicant (2)
Monthly Income (2)

Household Member (3)
First and Last Name (including applicant and children) (3)
Age (3)
Relationship to Applicant (3)
Monthly Income (3)

Household Member (4)
First and Last Name (including applicant and children) (4)
Age (4)
Relationship to Applicant (4)
Monthly Income (4)

Household Member (5)
First and Last Name (including applicant and children) (5)
Age (5)
Relationship to Applicant (5)
Monthly Income (5)

Hidden Collapse Stopper

Additional Income

	Monthly Income
Unemployment
Child Support
Disability
Social Security
Food Stamps
Total

Additional Income

Please indicate monthly income and benefits from additional sources.
Unemployment
Child Support
Disability
Social Security
Food Stamps
Total

Household Expenses

	Monthly Expenses
Rent/Mortgage
Lot Rent
Food
Consumers Energy
Water
Car Payment
Car Insurance
Phone
Gas Expenses (Work, Home, Errands)
Cable
Other
Total

Household Expenses

Please indicate monthly expenses.
Rent/Mortgage
Lot Rent
Food
Consumers Energy
Water
Car Payment
Car Insurance
Phone
Gas Expenses (Work, Home, Errands)
Cable
Other
Total
Should be Empty:

Assistance Request Form

Instructions:

Emergency Contact Information

Household Income

Additional Income

Household Expenses