Request for Assistance Application Request for Assistance Application InstructionsPlease assist individual (client) with this form, go over the Still Waters Ministries, Inc. Client Assistance Policy prior to filling this form. FOR ADMINISTRATIVE USE ONLYDate of Application MM slash DD slash YYYY Individual and Family Requesting AssistanceClient Name First Last Parent or Guardian Name First Last This is the family representative and most likely the one requesting assistance.Mobile PhoneHome PhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code How long has the client been in services with Still Waters? Not, nor has never been a client Former client New client - just began services Less than 6 months More than 6 months 1 year Over 1 year Reasons and Details of Assistance RequestPlease be detailed and specific.What kind of provisions are being requested? Assistance with Water Bill Assistance with Electric Bill Assistance with Gas Bill Assistance with Home Phone Bill Assistance with Mobile Phone Bill Assistance with Rent Assistance with House Payment Assistance with Car Payment Assistance with Vehicle Insurance Assistance with Vehicle Repair Assistance with Vehicle Fuel Assistance with Groceries or Food Assistance with Clothing/Shoes Assistance with Household Supplies Assistance with Medical Bill Assistance with Medical Supplies or Prescriptions Assistance with Toiletries Assistance with Travel Expenses Assistance with Other Please select all that apply.Describe specific need in more detail.Total Amount Needed Utility Company Name / Service Provider Name Account Number Date Due MM slash DD slash YYYY Turn Off Date MM slash DD slash YYYY Phone Number of Utility / ServiceAddressof Utility / Service Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Other Information pertaining to Utility or ServiceSubmitter - Still Waters Staff Members or Associates (Only)Provide contact information of person submitting this form.Name of Person Assisting in Submitting the Form First Last Association to Still Waters or Still Waters Ministries, Inc. Counselor/Team Leader CEO/Director/Manager/Administrative Sraff Still Waters Ministries, Inc. Board Member Still Waters Associate Email of Submitter Phone of SubmitterAttestation to Accuracy of Information and Witness to Request I acknowledge all of the information in this application is accurate based on the description given by the Requester listed above.Signature - Acknowledging Request for Assistance Δ
