Financial Help Application
This form is for someone to request financial help from Crossroads.
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Email *
Please complete the following section. All boxes MUST be checked before continuing. *
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What is your full name? *
What is your full address, including city, state, and zip code *
What is your phone number, including area code? (111)222-3333 *
Please list the NAMES, AGES, and RELATIONSHIPS of all those living in your household, including yourself. *
What type of help are you requesting? If requesting help through Godsend Garage, please include the year, make, and model of your car and describe the issue you are having with the vehicle.  If requesting money, please list each creditor, amount owed, any past due amounts, and dates the payments are due. *
How are you connected to Crossroads? *
What happened to you that put you in a position to request help *
What other sources of help have you contacted and what were their responses? (United Way 211, Township Trustee, Kokomo Rescue Mission, etc.) *
Please list ALL sources and amounts of aid/income coming in to your household (Social Security, Disability, Unemployment, Child Support, Spouse's job, Personal Job) EXAMPLE: SSI $820 monthly, child support $30 weekly, job $200 weekly *
By clicking I UNDERSTAND, your application will be submitted for review, and you understand that a deacon will contact you in sufficient time for you to receive an answer within 7 days.  You also understand that if the form is not fully completed your application could be rejected.                                                                                   *
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