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Ma'at American Aborigine Tribal Nation University
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Low Income Needing Assistance Form
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Date / Time
Date
Time
Name
*
First
Last
Email
*
City & State
*
Are you a verified low-income or DES SNAP benefits recipient?
*
--- Select Choice ---
Yes
No
Have you been affected by the government shutdown?
*
--- Select Choice ---
Yes
No
How many including yourself are in your household?
*
What are your immediate needs? (check all that apply)
*
Food
Shelter
Water
Money
Clothes
Toiletries
Transportation
GED/Adult Ed
Job Referral
Health Referral
If you checked "Money", what is the amount of your immediate need?
*
$0 - $50
$51 - $100
$101 - $200
$201 - $300
$301 - $400
More than $400
a benefits acknowledge
Are you willing to take the self-sufficiency course?
*
--- Select Choice ---
Yes
No
I acknowledge that I am completing this form of my own free will.
*
--- Select Choice ---
Yes, I acknowledge
No, I do not acknowledge
I understand that if I am selected to receive a donation, I must supply verification of my need.
*
--- Select Choice ---
Yes, I understand
No, I do not understand
Submit
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