NBOM ASSISTANCE REQUEST

NBOMFL Ministry cares about the welfare of others and offers assistance with meeting the emergency needs of an individual or family. We offer help with rent, utilities, transportation, medical expenses, groceries, and other necessities. We provide wisdom, direction, and guidance. If you are in need of assistance, please fill this form out as completely as possible. This is a necessary step to give you access to our resources. Once You Complete this form you will be contacted at the info you provide for an interview. After the interview we will offer what we can to assist you.

CONTACT INFORMATION

Your Name*

List Here the Phone Number You Prefer to Be Texted At*

Street number and Name of Street*

City, State and Zipcode*

PREVIOUS ADDRESS Street Name and Number*

City, State and Zipcode*

Your Email address*

example@example.com

Please list your social media handles here such as Facebook, Instagram, Linked In or other. If none, list none.*

Do you have a driver's License or Photo ID? If yes, provide DR # or a copy of your photo ID.

Social Security Number

Nick Names or Other names you go by (if applicable for identification purposes).

PERSONAL INFORMATION

Person or Persons you are living with*

Name, Age, & How Relationed *

RENT/OWN/LIVING WITH OTHERS (circle one and answer below) Who do you pay rent to, and what Amount of Rent monthly*

What type of transportation do you have? *

If Applicable and you have a car to drive, Is your car insured?

NoYes

If applicable vehicle Tag Number

Please Report any Employment, Personal, Government, Federal Assistance, Any form of financial help that you have right now. ( include all forms of income, child support, cash received from others, )

POST ALL FORMS OF INCOME AND/OR ASSISTANCE YOU ARE RECEIVING, THE AMOUNT, WHO YOU ARE RECEIVING IT FROM AND WHAT THE ASSISTANCE WAS.*

Do You Have Child Support and If Yes, Who Pays It?*

Food Stamps Received. How much? How often do you receive them?

Receiving Assistance from; Name and the assistance you are receiving

Church or support Groups who are or have helped you?

Current Employment

Previous Employment

References

Reason for applying for assistance

NBOM offers support through networking, coaching, and mentoring. Would you want NBOM to support you? What support would you like for NBOM to give you?

Additional information on helping NBOM assist with your needs.

By applying with NBOM, know your information is held in strictest confidence and not shared with anyone other than those who affliated with NBOM.

From time to time the supporters of NBOM need to know what their donations are being used for. May we have your permission to post information regarding your needs and how NBOM helped you without using your identification? YES NO

I AFFIRM THAT ALL THE INFORMATION IS THE TRUTH, AND I GIVE MY PERMISSION TO HAVE ALL INFORMATION CONFIRMED INCLUDING A BACKGROUND CHECK

Signature*

Date*

Date

CURRENT LIVING CONDITIONS:

INCOME