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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

    Month, Day, Year
    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.)
    (Please answer this question as you may need to provide proof of income.)
    (Please answer this question as you may have to provide proof of income.)
    (If you are employed, list your place of employment, and the name and phone number of your supervisor.) If not employed please explain why.
    (Please be advised that you may have to provide Social Security #"s for children, if asking for assistance for them.
    (If "yes' please explain)
    (Please answer honestly. Answering "yes' does NOT automatically disqualify you.)
    Answer "Yes" or "No." Please be advised if you answer "No", we may not be able to assist you.
    (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.)
    (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.
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