DEKALB EMERGENCY ASSISTANCE SERVICES REQUEST
CLIENT INFORMATION
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Type of assistance needed?
*
Rent
Mortgage
Utilities (other than water)
Water
Other
Reason for delinquency
*
INFORMATION SESSION REGISTRATION
You are required to attend an information session to receive assistance.
AFTER YOUR SUBMISSION, YOU WILL BE TAKEN TO THE ZOOM REGISTRATION LINK.
Please select the information session that you would like to attend.
Tuesdays morinings @ 9:30 AM 10:30 AM
Additional Comments
Submit
Should be Empty: