Heart to Heart Request for Assistance

FFCC Heart 2 Heart: Assistance Application

Please read and answer all questions to avoid any delays during the review and consideration process. Please allow 2-3 business days to hear back concerning your request. If we are unable to assist directly we will provide a list of possible agencies that work to provide related resources.
Adult Participant's Information
Referred By*
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
E-mail*
example@example.com
Birth Date*

MonthDayYear
Gender*

Employment Information:
Employment Status*
Employer's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Sources of Income:
Gross Household Income*

Household

Please provide requested information for all individuals living within the household.
Name

First NameLast Name
Birthday

MonthDayYear
Date
Name

First NameLast Name
Birthday

MonthDayYear
Date
Name

First NameLast Name
Birthday

MonthDayYear
Date
Name

First NameLast Name
Birthday

MonthDayYear
Date
Reason Assistance is Needed*
Type of Assistance Requested*
Assistance Disclaimer:

I, the undersigned, understand that review and completion of this form is not to suggest that any assistance requested is approved or guaranteed. The completion and review of this form confirms that Heart to Heart, a subsidiary of First Fruits Christian Center, will clearly review and consider providing assistance if and as resources and staffing availability permit.
Statement of Expectations:

I also understand that all participants are expected to adhere to the following rules:

1. I confirm all informaton provided is true and accurate at the time of request submission.

2. I understand this is not an approval of assistance being guaranteed but an agreement to review and consider.

3. I understand that request for furniture will require securing an additional booking through the Houston Furniture Bank in which I must be present and separate transportion must be arranged to avoid accural of delivery fees.

4. I understand that if Heart to Heart is unable to assist a list of referrals for related resources may be provided, however the referral does not serve as a guarantee of resources being available or approved.

5. I understand that any information found to be untrue will result in immediate denial of request.

6. I understand that request for food if approved, will be food items only provided.

I have read and understand the agreement and would like to proceed with application review and consideration.
Applicant's Signature*

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FFCC Heart 2 Heart: Assistance Application

Adult Participant's Information

Employment Information:

Household

Assistance Disclaimer: