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Fairgrove Family Resource Center Application for Services Please print
PROOF OF ADDRESS & INCOME, PHOTO ID AND SOCIAL SECURITY CARD ARE REQUIRED
Name: Date: Phone:     Date:    
How long have
Address: City:       you lived there?
                     
Do you own or rent? Landlord Name or Mortgage Co.        
Landlord Address:   City:   Phone:  
                     
HOW MANY PEOPLE LIVE IN YOUR HOUSE? # disabled:   # working:  
Please list all persons in household. Be sure to list everyone and all their information.    
Realtionship / Name Age Race Sex Social Security # Date of Birth ID #
Self                    
Spouse                    
Child                    
Child                    
Child                    
Child                    
Child                    
Parent/Other                  
LIST ALL MONTHLY INCOME   Employer Name Phone Number $$Monthly Expenses$$
Employment   $   Rent or Mortgage   $
Work 1st /AFDC   $         Lot Rent   $
Disability     $ Hourly Rate Hours Worked Electric   $
Disability     $   Gas/Heat   $
Social Security     $ $       Car Payment $
Unemployment   $ Auto Insurance $
Child Support   $ Spouse's Employer Phone Number Cable/Satelite $
Food Stamps   $         Home phone bill $
Government Energy Check $         Cell phone bill $
Income Tax Refund   $ Hourly Rate Hours Worked Water   $
Other     $         Child Support $
Other     $ $       Credit Cards $
TOTAL     $ Property Taxes $
Child Care $
Nature of Request (circle all that apply) Medication $
Food Electricity Kerosene Rent to own $
Heating oil Water Rent Life Insurance $
TOTAL   $
Reason for request?                  
                     
                     
I certify the above information is correct and make application to Fairgrove Family Resource Center for assistance
I give permission to Fairgrove FRC to make any inquires to confirm above information and need for assistance.
X                    
Signature             Date    
Date Commitment called in:           Amount$    
Vendor Contact:             Check #    
Vendor:     Address:         Date Paid  
Need $ Client $ FGFRC $ DCCA $
CCM $ S. ARMY $ DSS $ CHURCH $
Name on Bill: Account Number: Grant used: