Email address *
BLUFFTON SELF HELP FINANCIAL ASSISTANCE APPLICATION
*Por favor haga clic aquí para la forma español.
Date *
MM
/
DD
/
YYYY
Is this your first time requesting assistance? *Please limit your request for assistance to 1 during this time. If you have already requested assistance during the COVID-19 pandemic please do not submit again. *
Required
By signing this application, I (name below) certify that all information provided is true and accurate. I understand that this application is used to determine my eligibility for financial assistance. I understand that if I have intentionally submitted invalid, incomplete or fraudulent information in this application, Bluffton Self Help may deny this application based on this misinformation. I agree that Bluffton Self Help can verify all provided information. *
First Name & Last Name
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