A.N.C.A. Lifeline Online Request Form
Please take a moment to complete this confidential form if you find yourself in need of assistance during this time.
Your name and phone number.... *
What is your email address? *
Due to the COVID-19 pandemic, my family (or myself) find ourselves (or myself) in need of assistance with groceries, gas or pharmacy. *
I am requesting assistance in the amount of *
I use the same store for all my needs *
Required
The name of the food store I shop at locally is_______. *
Please write address and phone number of store listed above. *
The name of the pharmacy I use, if different from above. If same enter SAME *
Address and phone number of pharmacy I use, or national chain I frequent (ex. Walgreens, CVS, Rite-Aid). If same as above, enter SAME *
The gas station I use most often, if different from above. If it's the same please enter SAME *
Address and phone of gas station, or brand of gas you use (ex. Shell, Marathon, Speedway). If same as above enter SAME *
Brief summary of your need due to the pandemic . *
I find/have found myself in need *
Submit
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