CFO Bank of Goods Appliance Application Form

CFO Bank of Goods Appliance Application

to receive a Range, Dryer, Refrigerator, Dishwasher, or outdoor furniture set
The recipient will receive, at no charge, either a new refrigerator, dishwasher, electric range, dryer or outdoor furniture set. The recipient is responsible for delivery and installation. Eligible recipients must be 65 years or older AND head of the household. To qualify, you must live in one of the six zip codes in the south metro Atlanta area (30310, 30315, 30344, 30349, 30354, or 30291) . Please complete the form, in full, and attach/submit the requested documentation. Any application that is submitted but incomplete will not be considered. An interview (in-person or telephone) will be required of all qualified applicants prior to the approval of your application.

Due to funding, only one application per household will be accepted. An applicant can only apply for one appliance based on need. Due to limited supply, your preferred appliance is not guaranteed.
General Information
Name:*

PrefixFirst NameLast Name
Street address:*
Street address line 2:
City:*
State*
Phone number:*
Please enter the best contact number to reach you
Zip Code:*
Only the zip codes included are eligible for this application
Email address:
Sex:*

MaleFemale
Race:*

WhiteAfrican AmericanHispanicAsianOther
Marital Status:*

MarriedSingleDivorcedWidowed
Are you the head of the household?:*
Only seniors who are head of the household are eligible
# of Individuals in the Household:*
Date of Birth:*

MonthDayYear
Income Information
Total Annual Income:*
Please enter numbers only
Source(s) of Income (select all that apply):*

Social SecurityDisabilityPensionRetirement AccountEmploymentOther
Financial Information
The following documents are required to be submitted for review:
- Last pay stub from your source(s) of income
- Latest mortgage statement or rental agreement (if you own your home free of mortgage, then a copy of the deed/title)
- Latest utility bill (electric, gas, cable, or water). The bill must be in your name and address.
These documents can be uploaded through the link in this section or, if scheduled for an interview, brought with you for verification. The application is incomplete without these documents.
Please click on the button below to upload the required documents. *

Browse Files

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Current Monthly Expenses
Monthly Rent/Mortgage:*
Please enter numbers only; if none, enter 0
Monthly Food:*
Please enter numbers only; if none, enter 0
Monthly Electric & Gas:*
Please enter numbers only; if none, enter 0
Monthly Car payment & Insurance:*
Please enter numbers only; if none, enter 0
Monthly Telephone, Cell, Internet & Cable:*
Please enter numbers only; if none, enter 0
Other Monthly Expenses (e.g., public transportation, child care, water, etc.):*
Please enter numbers only; if none, enter 0
Total Current Monthly Expenses*
Appliance Request:

(appliances are limited and based on availability. Appliances are granted on a first come, first approved basis and are not guaranteed).
Please select the appliance you prefer (not guaranteed; please select only one):*

Dishwasher20.4 cu ft Refrigerator30 cu ft. Refrigerator4-piece outdoor furniture set7-piece outdoor dining table & chairs setElectric RangeDryer
Please provide any other information you feel is helpful in evaluating your application:
Certification
By submitting this application, I affirm that the above information is true and correct to the best of my knowledge. I understand if the information I give is determined to be false, the result will be denial of assistance, and I will be responsible for and expected to pay for services provided.
Should be Empty: