Assistance Requests for Pastor's Discretionary Fund
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Date
*
Name
*
Names of Other Adults in the Household
*
Name of Person Requesting Assistance on Behalf of Above Mentioned Person
Address
*
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AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Phone
*
# of People in Household
*
If there are children in the household, what are their ages?
If we have provided assistance to your family in the past - when and how did we help you?
If you receive Food Stamps, how much do you receive for your household?
What is your household income?
*
What are the sources of your household income?
*
What kind of help do you need?
*
Current Balance on Account or Amount Owed
Name of Company to be paid?
*
Account Number
*
If Rent Related, provide the name, address and phone # of your landlord.
Submit
Description
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