Christmas Assistance Application Form

Christmas Assistance Application, 2024

Fill out the form carefully for registration
Head of Household (Parent Name)*

First NameLast Name
Date of Birth*

MonthDayYear
MM-DD-YYYY
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email:*

Confirmation Emailexample@example.com
Children in Home (16 and under)

Fill out information for each child in your home. Do NOT include electronics.
First Child Name:*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age:*
Boy or Girl?*
Type Boy or Girl
Wish #1:
Type First Wish
Wish #2:
Type Second Wish
Wish #3:
Type Third Wish
Clothing Size (please indicate if it is children's size or adult size):
Type Size
2nd Child: Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age:
Boy or Girl?
Type Boy or Girl
Wish #1:
Type First Wish
Wish #2:
Type Second Wish
Wish #3:
Type Third Wish
Clothing Size (please indicate if it is children's size or adult size):
Type Clothing Size
3rd Child: Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age:
Boy or Girl?
Type Boy or Girl
Wish #1:
Type First Wish
Wish #2:
Type Second Wish
Wish #3:
Type Third Wish
Clothing Size (please indicate if it is children's size or adult size):
Type Clothing Size
4th Child: Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age:
Boy or Girl?
Type Boy or Girl
Wish #1:
Type First Wish
Wish #2:
Type Second Wish
Wish #3:
Type Third Wish
Clothing Size (please indicate if it is children's size or adult size):
Type Clothing Size
5th Child: Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age:
Boy or Girl?
Type Boy or Girl
Wish #2:
Type Second Wish
Wish #1:
Type First Wish
Wish #3:
Type Third Wish
Clothing Size (please indicate if it is children's size or adult size):
Type Clothing Size
6th Child: Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age:
Boy or Girl?
Type Boy or Girl
Wish #1:
Type First Wish
Wish #2:
Type Second Wish
Wish #3:
Type Third Wish
Clothing Size (please indicate if it is children's size or adult size):
Type Clothing Size
Monthly Income:

Must be filled out for everyone working in the family
Income for Head of Household*

First NameLast Name
Fill in all blanks. If not applicable, enter '0'
Amount received in Salary Monthly:
Type Amount
Amount received in Public Assistance Monthly:
Type Amount
Amount Received in Food Stamps Monthly:
Type Amount
Other Income Received Monthly:
Type amount and give explanation - or put n/a
Other Income Received Monthly:
Type amount and give explanation - or put n/a
Christmas Loan

Complete below if you are interested in applying for assistance.
Would you like apply for a Christmas loan?Yes No
Tax Preparation

Answer the questions below.
Are you interested in receiving a tax estimate? YesNo
Are you interested in Brewer Financial Firm preparing your taxes? YesNo
Are you interested in receiving a tax advance loan of up to $7,000? YesNo
Acknowledge

If selected, you must arrive by 11:30am to receive toys and accessories. Children must be present. You must bring your ID. Under no circumstances, will exceptions be made. If you are not there by 11:30am, your items will be given away. Brewer Financial Firm will not provide electronic devices as gifts. If chosen, you must confirm that you will be in attendance. If you do not respond to the email within 24 hours, you will be removed as one of the 50 families chosen. Families that are chosen may be photographed and will receive literature or information regarding tax preparation.
Signature

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Number of people in your home:
Type number
Should be Empty:

Christmas Assistance Application, 2024

Children in Home (16 and under)

Monthly Income:

Christmas Loan

Tax Preparation

Acknowledge