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Self Help Assistance Request
Eligibility Requirements:
Applicants must live in the counties of Los Alamos, Rio Arriba, Taos, or in Northern Santa Fe County (
north of the Santa Fe city limits
)
Applicants and their household must not have received direct financial assistance from Self Help in the past 24 months (
outside of Los Alamos
) or 12 months (
within Los Alamos
)
General Information:
Self Help, Inc. is a private nonprofit that offers emergency basic needs assistance. All assistance is offered at the discretion of Self Help, Inc.
Any approved assistance is paid directly to vendors and grant amounts are limited and based on available funding
Applicants are required to complete a phone intake and provide documentation (
copy of photo ID and bills
) for verification purposes
If you do not meet eligibility requirements, please call 211 to receive information about services in your area. You can also look at our list of
Community Resources
.
Once your assistance request is received, a staff member or volunteer will reach out to you by phone. Thank you!
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* Indicates required question
Full Name
(
This name should match your picture ID and the name on the bill for which you are requesting assistance
)
*
Your answer
Birth Year (
ex. 1965
)
*
Your answer
Can we contact you by text message using this phone number?
*
Choose
Yes
No
Phone Number
(Format Required: 555-555-5555. Please enter the best phone number to reach you at.)
*
Your answer
E-mail Address
Your answer
Physical Address
(
This physical address of your home. This address should match the service address if requesting utility to rental assistance
.
If you have no physical address, please just enter your city (e.g. Los Alamos, NM)
)
*
Your answer
Best Time of Day to Reach You
(
Please select the best time window to reach you
)
*
Choose
Morning (9a-Noon)
Afternoon (Noon-4pm)
Evening (4pm-6pm)
Number of People in Household
*
Choose
1
2
3
4
5
6+
Type of Assistance Needed
(
Select all that apply
)
*
Utility Bill (electric, gas/propane, water, phone, internet, or utility deposit -- Bill will be required.)
Housing (Rent or Deposit -- Valid lease or rental agreement will be required)
Medical Bill (Bill will be required)
Transportation (Quote/Bill will be required)
Home Repair (Quote/Bill will be required)
Other:
Required
Please tell us why your are seeking assistance?
(
Loss of job, illness, high expense, etc.
)
*
Your answer
If you are a caseworker completing this form on your client's behalf, please provide your name, phone number, and agency.
Your answer
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