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Potential clients, please fill out below:
Request for Financial Assistance 

(Jackson County residents only; Incomplete submissions will not be processed).

Amount:                Agency:                            Length of time:

Amount:                Agency:                            Length of time:

Enter First and Last names of all adults in the household

Select an option

Minor children in household:

(If none, enter 0)

Last year's taxes filed for ALL adults:

Select an option

Employment status of ALL adults in the household

(Monthly income source and amount for each adult:)

Adult #1 Employment:

$

$

$

$

Adult #2 Employment:

$

$

$

$

Adult #3 Employment:

$

$

$

$

$

Assistance received in the last 12 months:

$

$

$

Current housing situation and costs:

HUD/Section 8:

Power Bill applicants ONLY:

You will be contacted by phone if you qualify.

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