* Today's Date:

* Name (First, Middle Initial, Last):

* Address 1:

Address 2:

* City, State & Zip Code:

* How long have you lived at this address?

* Phone Number:

* Email Address:

* How many in your family? What ages?

* Are you currently involved in a local church?
Select OneYesNo

* If so, please state church and location:

* Present employer and location?

* If unemployed, list the last three places you have worked or applied for work, and the dates:

* What is your present need of assistance?

* Why did you come to Willowdale Chapel for assistance?

* What steps have you already taken to meet this need?

* Have you previously received assistance from Willowdale Chapel?
Select OneYesNo

* If YES, when? Amount?

* What need was covered by this assistance?

* During the past six months, have you received assistance from any of the following sources? If so, please indicate by their name:
Community Action
Other Church
Family
Loans
Other Source
None

* Please describe what type of assistance you were given:

* What is your plan to overcome your current financial struggles in order to become self-sufficient? How long do you anticipate it will take to become financially independent? What steps are you currently taking?

* Are you willing to participate in financial counseling?
Select OneYesNo

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