2020 APPLICATION FOR HOLIDAY BASKET
Must be submitted by December 1st

 

NAME_____________________________________________PHONE_____________________

SPOUSE/SIGNIFICANT OTHER___________________________________________________

EMAIL ________________________________________________________________________

STREET ADDRESS__________________________________TOWN_______________________
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)

EMPLOYED:  YES ____  NO ____  WHERE: ____________________________________________
SPOUSE/SIGNIFICANT OTHER:  YES____ NO ____ WHERE:_____________________________

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

 

OTHER INCOME:
PUBLIC ASSISTANCE:  $________ UNEMPLOYMENT: $ ________    SOCIAL SECURITY: $________                   WORKER'S CCOMPENSATION: $ ________________REACH-UP: $____________                                          CHILD SUPP
ORT: $ __________  FOOD STAMPS: $______________

OTHER INCOME: $ _____________

 

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



SIGNATURE _____________________________________ DATE ____________________

(Black River Good Neighbor Services reserves the right to refuse any application.)             Page 1 of 2
 

    Thrift Store 

37B Main Street

Ludlow, VT 05149

Food Shelf

37B Main Street

Ludlow, VT 05149

 Furniture Store

105 Main Street

Ludlow, VT 05149

Hours:

   Hours:

Monday-Friday

10AM - 3PM

Tuesday-Saturday

10AM - 4PM

Phone: 802-228-3663

Phone: 802-228-3663

Hours:

Friday & Saturday

10AM - 4PM

Phone: 802-228-7055