Share the Light 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 Non-binary Transgender Female Transgender Male Intersex Other Prefer not to say

Date of Birth

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

--Zip Code-- 28031 28036 28078 28107 28134 28202 28203 28204 28205 28206 28207 28208 28209 28210 28212 28213 28214 28215 28216 28217 28227 28244 28262 28269 28273 28277 28278 28280 28281 28282 28284 28285

Date of Disconnection:

How much do you need assistance with?

How much can you pay?

Did your financial crisis occur within 6 months of the date you are seeking assistance? --None-- Yes No

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

What documentation can you provide as proof of financial crisis? This will be documentation showing the cause of what has happened out of the ordinary, within the last 6 months, to put you in need of assistance. Rental and utility bills/notices cannot be used.

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: