Helping Hands Fund Application
Name _____________________________________________________________
Last First Middle
Address ____________________________________________________________
Box Number Street
____________________________________________________________
City State Zip Code
Phone (_______)___________-__________________Home(__) Mobil(__)
Email______________________________________________________________
Most recent adjusted gross income (from your W-2) $______________________
Employed (___) Unemployed (___)
Number of people living in the home. _______
Brief description of medical condition or conditions and any special circumstances that we need to know about. (Please limit to three to five sentences) We will ask for additional info if needed.
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Mail/Email: Acts Ministry, Inc. 1736 E. Sunshine Suite 216 Springfield, Mo. 65804
[email protected]
_______________________________________________________________________________________________
Signature/Date:_______________________________________________________________________________
