Society of St Vincent de Paul - Seattle / King County
ASSISTANCE REQUEST FORM

If you live in Seattle or in King County, use this form to request assistance from St Vincent de Paul.

If you live in Tacoma or Pierce County, please call St Vincent de Paul in Tacoma at 253-474-0519. Do not use this form.

If you live in Everett or Snohomish County, please call St Vincent de Paul in Everett at 425-355-3504. Do not use this form.

If you live anywhere else, please contact your local St Vincent de Paul. Do not use this form.

If you currently live outside of our area, but are planning to move to our area, or if you are having trouble filling out this form, please call our Helpline for assistance at 206-767-6449 Mon-Fri 8am-3pm (excluding holidays).

Your Information

First Name *

Last Name *

Building Name 🛈

Street Address *

Apartment

City *

State *

Zip Code * 🛈

Are you homeless?

I am currently homeless and the address above is my approximate location

Your Main Phone Number *

Your Alternate Phone Number

Email Address *

Confirm Your Email *

Date of Birth * +

Gender *

What ethnicity description do you prefer? * 🛈

Please check if any of the following apply to you

I am disabled

I am a US military veteran

I am a domestic violence survivor

Your Household

Number of Adults *

Number of Children (under 18) * 🛈

Your Request

RENT

Are you requesting help with rent? *

Yes	Not at this time

How much rent help are you requesting? ($) *

Do you currently have a eviction notice? *

No

Yes

Contact Name (landlord / owner / manager) *

Contact Phone (landlord / owner / manager) *

Contact Email (landlord / owner / manager)

Use this space to add any notes about your rent request. (Ok to leave blank)

0/512 characters

UTILITIES

Are you requesting help with utilities? *

Yes	Not at this time

How much help are you requesting? ($) *

Type of Utility *

Has service already been disconnected? *

No

Yes

Do you currently have a disconnect notice? *

No

Yes

Name of Utility Company *

Contact Phone for Utility Company *

Utility Account Number *

Use this space to add any notes about your utility request. (Ok to leave blank)

0/512 characters

OTHER HELP

Are you requesting help with any of these items? (check all that apply)

Use this space to add any notes about your other requests. (ok to leave blank)

0/512 characters

NOTE: to request any type of help not listed above, please telephone us at 206-767-6449, Mon-Fri 8:00am-3:00pm.

Almost done...

By submitting this form you consent to sharing this information within St Vincent de Paul for the purposes of reviewing your request and providing help.

Please note that placing a request does not guarantee that we will be able to help.

Food	Clothing	Household Items
Baby Items	Furniture	Beds

Society of St Vincent de Paul - Seattle / King CountyASSISTANCE REQUEST FORM

Your Information

Your Household

Your Request

RENT

UTILITIES

OTHER HELP

Almost done...

Society of St Vincent de Paul - Seattle / King County
ASSISTANCE REQUEST FORM