APPLICATION FOR ASSISTANCE

To apply for assistance through the RJ Foundation, please complete the following details:

First name

Last name

Address

Phone

DL#

SSN#

Date of Birth

Number of ADULTS in your household?

Number of CHILDREN in your household?

Name of your current employer

Please choose one income-based utility service you are applying for:

Financial assistance is provided directly to the landlord or utility company. Please enter your Landlord OR Utility Companies Name, Phone Number and Account # (if applicable)

Please select ONE of the additional services you are requesting:

By signing below, I hereby acknowledge that I am 18 years or older, the information provided is correct, complete and true, and I am legally authorized to submit this information on behalf of my household.

Signature

Signature field is empty.

MUST READ BEFORE SUBMITTING

Submission does not guarantee approval. Upon submission, applicant must EMAIL:

Birth Certificates for all children in the household
Proof of employment
Copy of Utility Bills OR Lease

Upon receipt of required information, your application will be reviewed for possible approval. Our Email - contactrjfoundation@gmail.com