Clothing Assistance Voucher

Clothing Assistance Voucher
Date

MonthDayYear
Date
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area CodePhone Number
Current or Most Recent Employer Information (List for both you & spouse) Name of Company and Phone Number

Children's names & ages of only those who are currently living with you on a daily basis.

Briefly explain the circumstances which brought about this need.

Where else have you gone for financial assistance in the last year? How much support did each one give?

Exactly what type of help are you asking for?

Children's Clothing VoucherChildren's Coat / Hat / Gloves VoucherChristmas Toy VoucherBook Bag / School Supplies VoucherOther

Are you requesting a voucher for a boy or girl?

BoyGirl

All of the above information will be verified by our Benevolent Committee and will remain confidential by all in the decision making process.

By electronically signing, you are giving permission to have appropiate personnel validate any of the above information.

Signature_____________________________________

Printed Name__________________________________

Date__________________
You prefer to be notified of acceptance via:

Should be Empty: