Community Aid Form

Persons investigating: Please complete the following information

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Date *

Email *

Referred by *

Assistance Requested and Reason *

If applying for assistance with AEP bill, have you applied for a balanced power bill? *

Yes No Not applying for AEP assistance

Have you requested or received aid from Indian Springs Community Chest in the past? *

Requested but was denied Requested and was approved Have never requested or received aid from Indian Springs Community Chest

Recommendations and Comments *

For Utility Payments attach bill if available. For Rent/House Payments include name and address

Service Provider *

Account Number *

Amount *

Name of Investigator 1 *

Name of Investigator 2 *

Executive Committee: Please complete the following information

Date *

Action Taken *

Case Number *

Check Number *

Approved By *

Submit