LWCC Assistance Request Form
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What type of assistance are you requesting?
Food
Clothing
Housing
When do you need assistance?
This week
Within 30 days
Long-term support
Employment Status:
Employed
Unemployed
Retired
Disabled
Number of Adults in Household
Number of Children in Household
Monthly Household Income
Additional Information:
Try to be specific about what you need.
I understand that Living Water Community Care (LWCC) is a faith-based nonprofit organization and that all services are provided as resources are available and based on individual need.
*
I Agree
I consent to be contacted by LWCC regarding my request for assistance and understand that my information will remain confidential and used solely for the purpose of providing support.
*
I Agree
Submit
Should be Empty: