SafeGround Assistance Request Form

SafeGround Assistance Request Form

Share your contact details, current situation, and the type of help you’re requesting so SafeGround can review eligibility.
Basic Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Method of Contact
Address Information
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
County
Are you currently experiencing homelessness?
Sleeping Location
Household Information
Number of Adults in Household
Number of Children in Household
Ages of Children
Income Information
Employment Status
Monthly Household Income
Release & Acknowledgment
I understand that completing this form does not guarantee assistance. Assistance is based on available resources, program eligibility, and funding.
I agree.
Veteran Status
Age Group
Gender
Are you receiving SNAP, Medicaid, SSI, or other public benefits?
Assistance Requested

Other
Assistance comments
Should be Empty: