CHARITY/HELPING HAND

Financial Assistance Portal

Welcome

2

Application

Application Form

Step 2 of 2 — Complete your application

First Name *

Last Name *

Date of Birth *

Home Address *

Phone Number *

Email *

Questionnaire

What is your reason for application? *

What is the TOTAL cost of your Bills? *

$

Are you a Citizen of the United States? *

YesNo

Your information is collected by CHARITY/HELPING HAND only to review your application and will not be sold or shared.

We won't call or contact YOU for any payment, everything is totally free!