Do you need assistance?

Date *

MM

DD

YYYY

Family/ Person in need *

First Name

Last Name

Please select one:

Applicant is a Greene County resident.

Applicant is a Putnam County resident.

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Phone

(###)

###

####

Phone

(###)

###

####

Please select all of the boxes below stating that you have read and understand the following: *

I understand that basic confirmation of financials will be provided and utilized as appropriate.

I understand that a background check may be required when appropriate.

I understand that the applicant demonstrates the need for a hand-up and not a hand-out.

I understand that a minimum of two reference checks is required.

I understand that Neighbors Helping Neighbors does not fund on-going expenses such as utility bills, repairs to rental properties or payments of loans.

2. Applicant's Vehicle Needs Repairs:

Please select one.

Vehicle is Running

Vehicle is NOT Running