Name *

First Name

Last Name

Phone Number *

(###)

###

####

What is your annual house hold income range? *

Gross annual income is the TOTAL income earned before taxes and other deductions for all household members.

$0-$20,000

$20,001-$30,000

$30,001-$40,000

$40,001-$50,000

$50,001-$60,000

$60,001-$70,000

$70,001-$80,000

$80,001-$90,000

$90,001-$100,000

Over $100,000

Have you applied for any kind of assistance from any other organization in the past 60 days? *

Yes

No

Disclaimer *

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, 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.

Yes, I agree

No

I authorize the release of my banking information to My Neighbor's House for their consideration in handling my request. *

Yes

No