Emergency Assistance Intake Form

Emergency Assistance Intake Form

SAINTS FRANCIS & CLARE OF ASSISI
*Please note that our monthly funds are limited. If your form is received after our monthly funds have been exhausted you will be notified of this circumstance. We suggest you reach out to other resources in the community or if the need still exists, please contact us again at the beginning of the next month.
Effective July 1, 2026

We will only be able to assist those living in the following zip codes in Johnson County, 46142, 46143, and 46106.
Todays Date

MonthDayYear
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Assistance Needed?

Other
If you have other needs, please click HERE for additional community resources.
Utility Company
Account Holder Name

First NameLast Name
Account Holder Birthdate

MonthDayYear
As of May 1, 2026 we are required to collect the birthdate of the account holder per the utility company.
Account Number
Amount Due
Date Payment Is Due

MonthDayYear
Date
Additional information we should know
Outreach Help Line

(317) 859-4673 ext. 126
Please verify that you are human
Should be Empty:

Effective July 1, 2026