2019 APPLICATION FOR HOLIDAY BASKET
Must be submitted by December 1st
(Delivery scheduled for Saturday, December 21st)

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NAME_________________________________________PHONE____________________

SPOUSE/SIGNIFICANT OTHER______________________________________________

EMAIL ___________________________________________________________________

STREET ADDRESS__________________________________TOWN_________________
                                           (house number needs to be visible)
DESCIBE HOUSE AND LOCATION ___________________________________________

_________________________________________________________________________

 

HOUSEHOLD MAKE-UP: (provide number of children for each age range)

Age 1-12 ______   Age 13-18 ______   Age 19-61 ______   Age 62+ ______

(If you have a child/children under age 13 please fill out the second page of this application,                           one page for each child)

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EMPLOYED:  YES ____  NO ____  WHERE: ___________________________________
SPOUSE/SIGNIFICANT OTHER:  YES____ NO ____ WHERE______________________

WEEKLY PRE-TAX WAGES:  SELF: $_________SIGNIFICANT OTHER: $_________

OTHER INCOME:
PUBLIC ASSISTANCE:  $________ UNEMPLOYMENT: $ ________    SOCIAL SECURITY: $________                REACH-UP: $_________  CHILD SUPPORT: $ __________ OTHER INCOME: $ ___________

EXPENSES:
RENT: $ _________  ELECTRICITY: $ _________  HEAT: $____________

FOOD PREFERENCE: (please check one)

FROZEN TURKEY (    )  FROZEN BAKED CHICKEN  (    )

SIGNATURE _____________________________________ DATE ____________________

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(Black River Good Neighbor Services reserves the right to refuse any application.)