INTAKE FORM
PO BOX 1996 Allentown, PA 18101 / 610-434-3117
Application Date:
*
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Month
-
Day
Year
Full Name of Applicant:
*
First Name
Middle Name
Last Name
Full Name of Spouse:
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email:
example@example.com
Contact Number:
*
I attend:
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Life Church Allentown
Life Church Bethlehem
Life Church Easton
Life Church Macungie
Life Church Nazareth
Life Church Reading
I am part of the following Discipleship Groups:
Have you previously received financial assistance from us before?
blanks
If so, when?
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Brief description of your current needs: Including specific type of assistance need and the amount.
Household Information
Number of Children in the home?
Number of adults in the home?
Is anyone in the home a veteran?
YES
NO
Employment Information:
Employer's Name
Employer's phone #:
Please enter a valid phone number.
Employer's address:
Street Address
City
State / Province
Postal / Zip Code
Have you exhausted all other avenues in trying to resolve the issues?
YES
NO
Have you trimmed your budget by removing extra expenses such as, cable TV, cell phone date plan, etc...?
YES
NO
Are you actively seeking employment or a promotion and/or helping spouse and adult children to find employment?
YES
NO
Have you contacted community service agencies for help such as, Unemployment Benefits, Salvation Army, Food Banks, Pathways?
YES
NO
Is this need an EMERGENCY that must be taken care of now?
YES
NO
A Copy of your valid photo ID is required for processing. Upload any documentation showing proof of financial need ie: lease, bill, eviction notice, etc.
Submit Application
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