SVdP at St. Thomas More Catholic Church Financial Assistance Request Form

"*" indicates required fields

Please select the zip code where you live:*

If you do not reside in one of the zip codes listed, you will not be eligible for assistance through the St. Thomas More St. Vincent de Paul Conference. Please call the main St. Vincent de Paul Georgia assistance line at 678-892-6163 to be connected with a local Conference that may be able to assist you.

Date

Head of Household Information

Name*

First Middle Last

Date of Birth*

mm/dd/yyyy

Email Address*

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Primary Phone Number*

Assistance Requested*

Utilities

Rent/Mortgage

Food

Other

Briefly describe your situation:*

Authorization for Release of Confidential Information

In consideration of the services to be undertaken or rendered on my behalf by the Society of St. Vincent de Paul, its members, agents or affiliated organizations (hereinafter referred to as “SVdP”), I, the undersigned, hereby authorize SVdP to receive, from any and all sources, and to release to any person or organization, any confidential information regarding me which may be necessary or useful to SVdP in relation to the services to be rendered. I hereby release SVdP from all liability in any way related to the receipt and/or release of said confidential information. I further understand that the release of this information does not guarantee that assistance will be provided, but that without such information my case cannot be presented to the Conference/Council for consideration.

Please sign below*