Client Inquiry Form

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

--Preferred Appt Venue--Phone In-Person at Matthews HELP Center First Available

How many people reside in your household ?

--Gender--Female Male

Date of Birth

Do you wish to recieve a text alert regarding your request? Message and data rates may apply. --SMS Opt In--Yes No

--Zip Code--28079 28104 28105 28226 28270

--Primary Need; MHC does not assist with hotel or mortgage payments--Rent Utilities Rent & Utilities Nonfinancial Assistance ONLY

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: