Christian Charity Request Form Hours: Monday, Tuesday, Thursday, Friday 10:00 a.m. to Noon Date* MM slash DD slash YYYY Phone*Name* First Last Age Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Marital StatusMarriedDivorcedSinglePartnerSpouse/Partner Name First Last Number of adults in household* Number of children in home Employed* Yes No If yes, name of Employer/Business and City If no, Have you applied for unemployment? Yes No Does anyone in your household receive government assistance? Disability Social Security EITC Housing Assistance Medicaid SNAP SSI TANF What do you need help with (rent, utilities, food and supplies, etc.) If you are requesting help with a bill please list the name of the company or landlord and total amount due for each bill.*If you are requesting help with a bill, bring it with you. If you need help with food, household cleaning products and personal hygiene items please fill out the below forms also. Our supplies are limited so you may not get all that you ask for.If you are not requesting Food or Caring Cupboard supplies, please scroll to the bottom of the page to submit your request.Food SuppliesFood & recipe in a bag (Limit 1 or 2 for large families) Tuna-noodle casserole Spaghetti & meat sauce Mac-n-cheese with hot dogs Hamburger casserole Chicken & noodles with Alfredo sauce Canned items: (Limit 8) corn green beans pork & beans mixed veggies fruit cocktail applesauce canned tuna canned chicken tomato soup chicken noodle soup canned evaporated milk Other: (Limit 12) Instant potatoes peanut butter jelly mac & cheese saltine crackers regular rice instant rice graham crackers elbow macaroni eggs cereal for adults cereal for children pancake mix pancake syrup instant oatmeal packets pop tarts pkg sliced cheese pudding cups ramen noodles - beef ramen noodles - chicken bread hot dog buns hamburger buns margarine mayo Meat Items: (Limit 3) Hamburger Hot dogs Bologna Cotto salami Pork loin chops Fresh Veggies and Fruit (when in season) Potatoes oninons lettuce tomatoes carrots celery peppers cucumbers apples oranges pears Caring Cupboard ItemsCleaning Products (Limit 8) Dish soap Toilet cleaner All purpose cleaner Comet or Ajax Trash bags Aluminum foil Laundry Detergent Liquid fabric softner Dryer sheets Clorox Spray & wash Dishwasher Soap Paper products Toilet paper Kleenex Paper towels Personal hygiene products (Limit 8) Shampoo Conditioner Deodorant for woman Deodorant for men disposable razors Shaving creme Bar of soap Liquid hand soap Hand/body lotion Body wash Band-aids Cotton swabs Toothbrush Toothpaste Feminine hygiene tampons (regular) Feminine hygiene tampons (super) Feminine hygiene pads (regular) Feminine hygiene pads (super) Diapers Baby wipes Size NB Size 1 Size 2 Size 3 Size 4 Size 5 Size 6 Pull-ups size 2T-3T Pull-ups size 4T Pull-ups size 5T Pull-ups size 6T Δ