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Randolph County Ministerial Alliance Assistance Application
Our financial assistance is available for all Randolph County Residents. All fields are required.
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* Indicates required question
Email
*
Your email
Household Member 1: Provide Full Name and Age
*
Your answer
Household Member 2: Provide Full Name and Age
Your answer
Household Member 3: Provide Full Name and Age
Your answer
Household Member 4: Provide Full Name and Age
Your answer
Household Member 5: Provide Full Name and Age
Your answer
Household Member 6: Provide Full Name and Age
Your answer
Full address, including City, State and Zip
*
Your answer
Phone Number, including Area Code
*
Your answer
Does anyone receive EBT/Snap Benefits?
List the monthly dollar amount for the entire household.
*
Your answer
Who works in the home?
List all names and place of employment.
*
Your answer
If an adult does not work, please explain the reason
*
Your answer
Total Monthly Income for the household?
*
Your answer
Housing?
*
Rent
Own
Other:
Mortgage Payment or Rent Dollar Amount
*
Your answer
We offer help on rent, utilities, prescriptions, and other items that make sense. What do you need help with today?
*
Rent
Water
Electricity
Prescriptions
Other
Why are you unable to pay this bill?
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Your answer
Are you able to pay any amount on this bill? If so, how much?
*
Your answer
What is your ACCOUNT NUMBER and whose NAME is listed on the bill you would like help with? If you are needing rental assistance, provide the landlords name and phone number.
Your answer
Have you applied for any other help?
*
Yes
No
Do you attend church in Randolph County?
*
Yes
No
Other
If you attend church, which one?
Your answer
Send me a copy of my responses.
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