United Way Emergency Assistance Intake Form
Name (First) *
Your answer
Name (Last) *
Your answer
Email *
Your answer
Street Address *
Your answer
City *
County *
Phone number *
Your answer
Do you work or live in Jackson or George Counties? *
Does anyone in the household receive any type of SSI, Social Security or Disability? *
What type of assistance are you needing help with? *
What caused you to fall behind on the bill? *
Your answer
Your answer
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