Johnson McDaniel Emergency Assistance Form

Name

Phone Number

Address

Birthdate

年

/

月

/

日

Do you identify as a person of color?

Yes

No

清除所选内容

Are you currently receiving any of the following?

Housing assistance (DSS, ESG, Section 8)

Free/Reduced Lunch

WIC

SNAP/EBT

Public Assistance/Cash Assistance

Medicaid

HEAP

What is the dollar amount of financial assistance that you are requesting? Are you requesting it be paid directly to you or to a vendor?

Please provide details regarding your request for emergency assistance. Requests should not exceed $500.