Low Income Needing Assistance Form

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by State a

Date / Time

Date

Time

Name *

First

Last

Email *

City & State *

Are you a verified low-income or DES SNAP benefits recipient? *

Have you been affected by the government shutdown? *

How many including yourself are in your household? *

What are your immediate needs? (check all that apply) *

If you checked "Money", what is the amount of your immediate need? *

Are you willing to take the self-sufficiency course? *

I acknowledge that I am completing this form of my own free will. *

I understand that if I am selected to receive a donation, I must supply verification of my need. *