Assistance Form

To request financial assistance, please complete the form below and click on the "Submit" button. Or, if you prefer, you can download the form and mail it to us.

* Denotes required fields

Name:

Email:

*Name
*Street Address
*City
*State, Zip
*Phone Number(s)
# of Dependents
*County of Residence
Have You applied before (if so, how many times and when?)
Do You/Are You...	Live in Merritt Township?
	Work full time in Merritt Township?
	Belong to a non-profit in Merritt Township?
	A member of a church in Merritt Township?
*Reason for Request	Food Basket (check one): Yes No Monetary reason (checks go directly to the establishment). Please indicate what bill(s) you want paid and why.
Employer Name
Employer Street Address
Employer City
State, Zip
Employer Contact
Employer Phone
Spouse Employer
Spouse Employer Street Address
Spouse Employer City
State, Zip
Spouse Emp Contact
Spouse Emp Phone
Have you applied to any other agencies for help for this matter? (Dept. Health and Human Services, Truenorth, Mid Michigan Community Action, Salvation Army, etc?) What was the outcome?

Please Note: You are only eligible for assistance 1 time per year and no more than 3 consecutive years.