Assistance Request

Duration at current residence

Landlord's Phone Number

# of Household Members *

Are you currently employed? *

Yes

If you are not employed, why not?

If not employed, how long have you been unemployed?

Are you currently looking for work?

Yes

Is anyone in your household employed at this time?

Yes

Are you receiving aid, financial or otherwise, such as unemployment insurance, social security, welfare, SNAP, or worker's compensation?

Yes

Who referred you to us?

What is your need? Please be specific and provide documentation where needed.

Who has helped you in the past?

Have you contacted anyone else with your current need?

Yes

Whom may we contact to verify your need? If we can not contact individuals to confirm your need, we may not be able to assist you.

Please provide a current form of picture identification, such as a driver's license. In addition, upload supporting documentation that confirms your need. Please remember, our church is not a government-assisted agency. Our funds and resources are limited and are a result of direct donations from our congregation.

By submitting this form, you grant us permission to evaluate and advocate as needed using any information provided in this Assistance Request Form.

Choose File

Address

1001 Old Snellville Hwy
Lawrenceville, GA 30044

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1001 Old Snellville Hwy
Lawrenceville, GA 30044