Application for Assistance

Date*

Name*

First Last

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP / Postal Code

How long have you lived in Hardin County?*

At this address?*

Phone*

Have you or anyone in your household received assistance from Hardin or McNairy County Jesus Cares before?*

Yes
No

If so, when?

What type of assistance did you receive previously (optional)?

Food
Financial

List all household members/relationship/DOB/income for all living in household.*

Total monthly household income amount?*

What do you need assistance with?*

Food (Must Apply In Person - Monday thru Friday - 11am to 4pm)
Rent
Electric
Gas/Water
Homeless
Transitional Recovery House (Sober Living)
Other

Hidden

What dollar amount are you needing (if known) from above requests?

*Food* Number of adults and children (under 18) in household?

*Rent* Landlord address and phone number?

*Electric*

*Gas/Water*?

Other. Explain:

Does anyone in your household participate in any of the following programs? (check all that apply)*

Select All
SNAP Benefits
Work Essentials Program
SSI
Low Income Housing Energy Assistance Program
Live In Public Housing
None of the above

Who referred you to us?

Church Membership?

Consent*

I Agree to the Notice Below

The information I have provided is true and correct to the best of my knowledge. I give permission for HC Jesus Cares to communicate with service providers and other resources in an effort to verify the information on this application and to provide advocacy and case management assistance using Charity Tracker networking. I understand that my consent automatically expires after one year or sooner at my written request. I agree not to hold HC Jesus Cares liable for any release of information during active status of this application or signed release. I understand that providing incorrect or incomplete information may result in being denied assistance.

Client signature:*