ASSISTANCE REQUEST FORM

Personal Information

Full Name

Date of Birth

Phone Number

Format: (000) 000-0000.

Email Address

example@example.com

Address

City

State

Zip Code

Household Information

How many people live in your household, including adults and children?

This helps us understand the number of individuals requiring assistance.

What are your total monthly household expenses (e.g., rent, utilities, groceries)?

This allows us to assess your financial obligations and needs.

What is your total monthly household income from all sources?

This information is essential for evaluating your eligibility for assistance.

Assistance Needs

Domestic Violence SupportChildhood Obesity SupportHIV/AIDS SupportOther

What specific needs are you seeking from the program selected above?

How did you hear about our assistance program?

Have you received assistance from us or any other organization before?

If yes, please provide details

Specific Circumstances

Please describe your current situation and why you need assistance?

Are there any specific challenges you are facing (e.g., job loss, medical issues, etc.)?

Are you currently receiving any government assistance?

If yes, please specify.

Additional Information

Do you have any special needs or considerations we should be aware of?

Is there anything else you would like us to know that may assist in your application?

Consent

Do you consent to our organization using your information to provide assistance?

Consent is given for the use of family photos for nonprofit purposes and it is understood that the family’s story and images may be featured in social media posts and blog entries.

Signature

Date