Name
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First Name
Last Name
Email
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Address
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How long have you lived in Greene County?
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What is your date of birth?
MM
DD
YYYY
Phone Number
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(###)
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What is the best way to contact you?
Briefly describe what help you are needing?
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What steps have you taken to address this concern?
Please provide the names and ages of the people in your household.
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Are you currently employeed?
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What is your annual house hold income range?
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Gross annual income is the TOTAL income earned before taxes and other deductions for all household members.
Do you
In which county to do you pay taxes?
Have you applied for any kind of assistance from any other organization in the past 60 days?
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What is the total amount you are seeking help with?
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How much are you able to provide to help with this need?
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What is your long-term solution to this issue?
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How did you hear about us?
Please share any other information you would like us to know below.
Disclaimer
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By checking "Yes" below, I certify that the information I have provided is accurate and complete. I authorize My Neighbor's House to share or obtain relevant information with other organizations, including banks, utility companies, employers, and landlords, that are relevant to my request. I acknowledge that My Neighbor's House does not discriminate based on race, gender, sexual orientation, age, disability, religion, or national origin in providing assistance. I agree to cooperate if a representative of My Neighbor's House requests verification of any information given in this application.
I understand that My Neighbor's House will not automatically provide the services that I have requested.
I certify this request on behalf of all minors in my household and I understand and agree to the terms outlined in this disclaimer.
Furthermore, I acknowledge that My Neighbor's House, it's partners, and volunteers are not liable for any damages, losses, or injuries that may occur as a result of the services provided. I understand that participation with My Neighbor's House is voluntary and that I assume all risks associated with receiving services. My Neighbor's House make no guarantees regarding availability or quality of services provided.
I authorize the release of my banking information to My Neighbor's House for their consideration in handling my request.
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