Application for Financial Assistance
First name
Last name
Email
Address
Mobile or Home Phone Number
Marital Status
Single
Married
Divorced
Other
Including yourself, how many adults are in your household? What are their ages?
Names and ages of children who currently live with you.
Most Recent Employer Information for You/Spouse/Adult Household members
Total Household Monthly Income
Can you briefly explain your need.
Have you received assistance from churches/non-profits in the last year? If so, where?
Check all that apply
SNAP benefits
SSI/Disability
Unemployment
Child Support/Alimony
Other
None of the Above
Are you willing to confidently meet with our team who may ask additional financial questions?
Yes
No
I give my permission to have GMJ validate the above information.
Yes
No
I acknowledge that the above information is true and accurate to the best of my ability. Please print your name
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Application for Financial Assistance