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*Please note, if you have ever received asistance from us before, you cannot receive assistance again.
Your application will be flagged and rejected.
GET HELP FORM
Indicates required field
Date of Birth
Month, Day, Year
Alternate Phone Number
Please list full address. (Street, City)
Please put the person's name, address and phone number, how you know them and how long you have know them.) (This can be a friend, relative, case manager, etc.
Please list the name, address and phone number of a past employer, supervisor, coworker, or case manager. (This cannot be a friend or relative.)
TYPE OF GOVERNMENT AID AND OTHER FUNDING CURRENTLY RECEIVING
(Please answer this question as you may need to provide proof of income.)
Monthly Household Income
(Please answer this question as you may have to provide proof of income.)
Current or Previous Employer
(If you are employed, list your place of employment, and the name and phone number of your supervisor.) If not employed please explain why.
Number of people living in household
(Please be advised that you may have to provide Social Security #"s for children, if asking for assistance for them.
Names of all people living in the household over the age of 18
Have you or anyone in your household been arrested in the past five years, or currently on probation?
(If "yes' please explain)
Have you or anyone in your household, ever been convicted of a felony?
(Please answer honestly. Answering "yes' does NOT automatically disqualify you.)
I give permission for Favors Forward Foundation to discuss my situation with other agencies that may be of assistance.
Answer "Yes" or "No." Please be advised if you answer "No", we may not be able to assist you.
How can we use our time, talent and treasures to meet your current hardship?
(Please explain your need and circumstances in detail. Failure to do so will result in having your application rejected and you will have to resubmit another application.)
In return for the time, talents and treasures of others, I am willing to sign an agreement to donate my time, talents and treasures to someone else.
(You will be required to sign a contract to Pay It Forward to another, when you are able to do so. If you have any questions, call 570-447-5697 for clarification.)
Write the name and phone number of the person who saw you fill out the form.