Assistance Application

Home Assistance Application

Personal Information

Name

Home Address

County

City

State

Zip Code

Mailing Address (if different)

County

City

State

Zip Code

Contact Information

Home Phone

Work Phone

Cell Phone

Email Address

Important

Have ANY members of the household ever been convicted of or been charged with a crime? (It could be as simple as a misdemeanor driving violation or as serious as armed robbery.) We do extensive background checks.

Yes

If yes, please describe (include dates):

Has the family or anyone in the family been involved in a lawsuit?

Yes

If yes, please describe state and county where filed, parties involved, and the nature of the dispute (include dates):

Have you ever filed for bankruptcy?

Yes

If yes, please describe:

Have any members of the household been on television?

Yes

If yes, please describe (include dates):

Does anyone in the household have a Facebook, blog or website of any kind?

Yes

If yes, please list all of the addresses:

Please describe what kind of volunteer work or community service you and/or your family has been involved in:

Your and/or your family's proudest achievements and/or recognitions by the community?

Please list make, model and year of all cars owned by household:

If selected, will W2s and/or tax returns for the last two years be available? (Please do not include them now.)

Yes

If not, why?

If you are nominating someone, please include your information

Your Name

Street Address

County

City

State

Zip Code

Your Contact Information

Home Phone

Work Phone

Cell Phone

Email Address

PART 2 – YOUR STORY (Mandatory)

Please summarize the family's CURRENT situation. What makes them deserving? What makes the situation unique? (Help us. Be concise.)