Community Connection

HALO Club Request Form

A Request Form is required for consideration.
ALL FIELDS ARE REQUIRED - INCOMPLETE FORMS MAY BE REJECTED.

Personal Information

Name:

Address:

City:

State/Zip:

Phone:

(xxx-xxx-xxxx)

Best Time to Reach You:

Your Name and Contact Information
(if filling out for a client):

Name and Ages of Adults and Children Living at Home

List Amounts of All Monthly Bills

Sources of Income

Currently Employed?

Yes

Employer:

How long?

Unemployed for how long?

Why?

Net Monthly Income:

Spouse
Currently Employed?

Yes

Employer:

How long?

Unemployed for how long?

Why?

Spouse's
Net Monthly Income:

Please List Monthly Amounts of All That Apply

Retirement:	$	Child Support:	$
Government Assistance:	$	Aid to Dependent Children (ADC):	$
Social Security:	$	Disability:	$
Food Stamps:	$	WIC:	$
Miscellaneous (Please List):

Total Income:	$

Assistance

Item Requested:		Cost: $
Describe reason for making this request:

Other Agencies Contacted: