CLC Benevolence Form

Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you employed? *

Yes

No

Are you collecting unemployment? *

Yes

No

Type of Assistance Needed: *

Choose only 1.

Rent/mortgage (partner with 211)

Electric and water bills

Food

Fuel

Medical Bills

Other

Mailing address for the check:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country