The Giving Neighbors - Application Form

Application Form

For all other inquiries contact us at:

Application

Full Name	E-Mail Address
Home Phone	Work Phone
Current and Verifiable Address (Street, City, State)
Employer's Name	Employer's Phone
Employer's Address (Street, City, State)
Your direct supervisor or manager's Telephone Number
Your direct supervisor or manager's Email Address
If Self Employed:
Date of last job performed	Contact/Reference of last job performed
Name	Phone
Address (Street, City, State)

If Unemployed:
Last Employer's Name	Last Employer's Contact Person
Last Employer's Address (Street, City, State)
Last Employer's Phone	Last Day of Employment

The amount of your total Net Monthly Income

The total amount of the Expense

The purpose of the expense *description of the circumstances surrounding the application or the applicant’s type of supplies and quantities needed (if applicable)

Please describe the circumstances surrounding your application

A copy of a valid Prescription	Will Fax Not Applicable

A copy of the Doctor's Invoice, Doctor’s Advise Statement of Need, etc (bill/invoice/estimate) to substantiate the expense or need	Will Fax Not Applicable

Letter from Employer to confirm employment	Will Fax Will Email

Three Letters of Reference from individuals to substantiate this request	Will Fax Will Email

Copy of the last payment received (required for self employed)	Will Fax Will Email

Copy of last years tax return (required for self employed)	Will Fax Will Email

Copy of your Driver’s License or Government Issued ID	Will Fax

Copy of any recent Utility Bill in your name and sent to your legal residence	Will Fax

Copy of any document showing the amount you pay monthly for your Housing (i.e. rent or mortgage payment) and to whom it is paid. A contact name and telephone number of the mortgage company or landlord must accompany this information.	Will Fax

Copy of the most recent Pay Stub for every working member of your household	Will Fax

If you or any member of your family is receiving Social Security Disability or Social Security Income, a copy to verify these incomes showing your monthly benefit amount must be provided.	Will Fax Not Applicable

Questions: