Application for Assistance
Washington Street Church of Christ
Contact: 931-652-2396 to Schedule Assistance
Email address *
Date *
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DD
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YYYY
Name *
Your answer
Address *
Your answer
Telephone Number *
Your answer
Age *
Your answer
Marital Status *
Name of Spouse *
Your answer
Age of Spouse
Your answer
Number in Household
Your answer
Name and Age of Children
Your answer
Are you Employed? *
Where? (Provide Contact Information) *
Your answer
Is your Spouse Employed? *
Where? (Provide Contact Information) *
Your answer
If not employed, have you applied for a job in the past 2 weeks? Where? *
Your answer
What is your total monthly income? *
Are you currently seeking any other assistance? *
Your answer
Do you receive an of the following? *
Required
Do you or anyone in your family smoke? *
Do you or anyone in your family drink? *
Do you attend Church? *
Where? *
Your answer
What type of assistance are you applying for today? *
Your answer
Who referred you to us? *
Your answer
I give Washington Street Church of Christ permission to contact any federal/state/local agencies that might know of my circumstances or that might be able to help me with the needs requested above. *
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