Green Sheet
White County Emergency Relief Coalition
Last Name *
Your answer
First Name *
Your answer
Social Security Number *
Your answer
Street Address *
Your answer
City, State, Zip *
Your answer
Phone Number *
Your answer
Best Emergency Contact *
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Other Emergency Contact
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Email Address
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Request #1: Amount *
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Request #1: Person/Company to Pay *
Your answer
Request #1: Payee's Address *
Your answer
Request #1: Payee's Phone Number *
Your answer
Request #1: Payee's Email
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Request #2: Amount
Your answer
Request #2: Person/Company to Pay
Your answer
Request #2: Payee's Address
Your answer
Request #2: Payee's Phone Number
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Request #2: Payee's Email
Your answer
Request #3: Amount and Payee Name, Address, Phone Number, and Email
Your answer
Request #4: Amount and Payee Name, Address, Phone Number, and Email
Your answer
Describe the reason you are needing assistance. *
Your answer
Have you ever received financial assistance from the trustee? Explain with as much detail as possible. *
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Have you ever received financial assistance from White County charities or churches? Explain with as much detail as possible. *
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Select all of the following that describe you: *
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By writing your first, middle, and last name below, you are releasing this information to any and all human service agencies in White County who offer or support direct financial emergency aid. *
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