ASSISTANCE REQUEST

Please fill out both sides of this application completely.

Give as much information as possible to assist in the review of your request.

Attach your copies of PROOF of INCOME , MARRIAGE CERTIFICATE/ DIVORCE DECREE
OR INCARCERATION FORMS required to represent your need for assistance.

Date of Application * +

Have you been abandoned, widowed, spousal incarceration? *

YES

NO

Date of abandonment, widowed or spousal incarceration?

Are you a U.S. Citizen? *

YES

NO

FAMILY INFORMATION

APPLICANTʹS NAME: *

DATE OF BIRTH: *

NUMBER OF CHILDREN UNDER 18: *

HOUSEHOLD MEMBERS LIVING WITH YOU (not listed above )

	FIRST AND LAST NAME	RELATIONSHIP	DATE OF BIRTH
1	FIRST AND LAST NAME	RELATIONSHIP	DATE OF BIRTH
2	FIRST AND LAST NAME	RELATIONSHIP	DATE OF BIRTH
3	FIRST AND LAST NAME	RELATIONSHIP	DATE OF BIRTH
4	FIRST AND LAST NAME	RELATIONSHIP	DATE OF BIRTH
5	FIRST AND LAST NAME	RELATIONSHIP	DATE OF BIRTH

FULL ADDRESS: *

CELL PHONE? *

EMERGENCY PHONE *

E‐Mail: *

EMPLOYMENT INFORMATION

Employer *

Location *

How Long have you been employed? (years) *

If Unemployed ‐ How Long (years)? N/A if not applicable *

Reason for Unemployment? N/A for not applicable *

Primary work experience/education

Please describe circumstances that led to your need for assistance *

Who referred you to MAW Charities? *

If Agency, case worker or employee name? *

Case Worker Email *

Case Worker Phone? *

PLEASE LIST ALL INCOME

MONTHLY INCOME

	Current Monthly Income
Applicant's Wages	Current Monthly Income
Disability Income	Current Monthly Income
Unemployment Income	Current Monthly Income
Child Support (Receiving)	Current Monthly Income
Any Other Income	Current Monthly Income
Total Monthly Income	Current Monthly Income

CHILDREN

	Child #1	Child #2	Child #3
First and Last Name	Child #1	Child #2	Child #3
Age	Child #1	Child #2	Child #3
Extracurricular Activities	Child #1	Child #2	Child #3

TYPE OF ASSISTANCE NEEDED

Transportation *

YES

NO

What type of transportation assistance is needed?

Make/Model of Car

Childcare *

YES

NO

Continuing Education *

YES

NO

What type of education?

High School

Trade School

Higher Education (College, etc.)

Other Other

Children's Program *

YES

NO

Children's Activities

Upload all necessary forms including: (Marriage certificate, Tax Return, and proof of yearly salary)

*Please keep file sizes under 500kb**

Tax Return *

Marriage Certificate *

Drivers Licence *

Proof of yearly salary *

* I declare that the information provided by me on the above form is true and correct to the best of my knowledge and belief. I also confirm that in the event any information provided by me is not true or incomplete may result in your application being delayed or rejected in its entirety.

E-Signature *

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