Sapphire Dragonfly Safe Haven Nonprofit Short Term Assistance Request
Please use this form to submit a request for short term assistance and some one will get back with you.
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Email *
First Name *
Last Name *
Contact # *
Date Of Birth *
MM
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DD
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YYYY
Do you have minor children under 18 for whom you are responsible to provide for?  *
How many children do you provide for? *
Are you currently employed? *
Are you legally married? *
What type of short term assistance are you seeking? Check all that apply. *
Required
If you are requesting Utility Bill Assistance or Emergency Cash Assistance, please enter the dollar amount (ex. $x.xx) you require and the name of the company and account number it is to be paid to (ex. Southern Power Company).
When do you need this assistance by? *
Required
A copy of your responses will be emailed to the address you provided.
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