Client Inquiry Form

Have you or a household member received services from Matthews HELP Center? --None--Yes No

How many people reside in your household ?

--Gender--Female Male

Date of Birth MM/DD/YYYY

--Zip Code--28079 28104 28105 28226 28270

--Primary Need--Rent Utilities Rent & Utilities Gasoline Nonfinancial Assistance ONLY

--Do you need help with food or clothing?--Food Only Clothing Only Both Food and Clothing I do not need assistance with either

Date of Eviction/Disconnection:

How much do you need assistance with?

How much can you pay?

Briefly describe the situation that has caused you to seek short-term emergency assistance. What has happened out of the ordinary?

Financial plan moving forward:

I understand that this submission does not guarantee that Matthews HELP Center will be able to assist me with my request: