Request for Assistance Application

Please fill out the following application. Once you submit this form, a team member will review it and get back to you to discuss your situation. The information you provide helps us more fully understand your need and provide the best solution we can. Your data will be kept as confidential as possible. Occasionally it may be necessary to share some information with other organizations to help provide better care. Please note: We are not able to provide short-term or transition housing, or hotel stays.

If you need help with food or clothing, try contacting one of these local organizations (services and information subject to change without notice):

City of Refuge: 840 Park Ave, 208-552-5575, Dinner: 6pm Daily

CLUB Drop in Center: 1904 Dakota Ln, Ammon 208-529-4673 Lunch: Noon Mon/Wed/Fri

Community Food Basket: 351 W 14 th , 208-524-0994, Mon 3-5pm; Tue/Wed/Fri 4-5pm; Thu 5-6pm

IF Soup Kitchen: 301 S Blvd, 208-557-5750, Lunch: Noon Mon – Sat

Salvation Army: 605 N Blvd, 208-522-7200, Clothing, other assistance

St Vincent DePaul: 805 S Holmes, 208-522-6280, Clothing, other assistance

Personal Information

Name

First Name

Last Name

Phone Number

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please list all others at this address. Include name, age, and relationship to you:

Put N/A if you live alone.

We want to know:

Please describe your request for assistance:

How much do you pay each month for this/these bills?

Are you behind in this/these bills?

Yes

If so, how many months are you behind and by what amount?

Please describe your plan for paying your bills/rent next month:

Please list the amount, the company, billing address, and phone # for this/these bills (for rent help, also include your landlord contact and, if possible, email address):

Please enter your income and source(s):

Employer

First Name

Last Name

Employer phone number

(###)

###

####

Please enter total household income:

How can we pray for you?

Would you like to meet with a pastor?

Yes

“I understand that any assistance received from Christ Community Church (CCC) is freely given without any obligation for repayment. I understand that CCC may limit or deny this or additional help for any reason. I understand that if I receive this aid, I will not be eligible for further aid for a period of twelve months.”

I understand

“I authorize Christ Community Church to release any of the above provided information to any other social service agency as might be necessary, in the judgment of CCC, to provide me assistance. I release CCC, its staff and volunteers of all liabilities and claims whatsoever arising out of any monies and/or services provided.”

I authroize

Sign Here

Type your full name

Date

YYYY