BLOOD RIVER BAPTIST ASSOCIATION
C.A.M.P. Assistance Application
Client Information:
Full Name (whose name is on the account)
*
First Name
Last Name
Address
*
Street Address
City
State
Zip Code
Phone Number
*
E-mail
*
example@example.com
Name of Utility Company and Phone #
*
Amount due and due date:
*
Any information that might be helpful when considering your application for assistance:
A picture of utility bill (must show name, address, account number and amount due)
*
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A picture of photo ID of whose name in on the account.
*
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Should be Empty: