Application for Assistance
Washington Street Church of Christ
Name *
Date *
MM
/
DD
/
YYYY
Email *
Address *
Phone number
Age *
Marital Status *
Name of Spouse *
Age of Spouse *
Number in Household *
Are you Employed? *
Where? (Please provide Contact Information) *
Is your Spouse Employed? *
Where? (Please provide Contact Information) *
What is your Total Monthly Income? *
Are you currently seeking other assistance? *
Do you receive any of the following? *
Required
Do you smoke? *
Do you drink? *
Do you attend church? *
Where? *
What type of assistance are you applying for today? *
Who referred you to us? *
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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