APPLICATION FOR ASSISTANCE

RJ Foundation Outreach is a non-profit organization providing supportive assistance. Please complete the following form

First name

Last name

Address

Phone

DL#

Date of Birth

SSN#

Number of ADULTS in your household?

Number of CHILDREN in your household?

EMPLOYER - Name, Address and Phone Number

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

Please select ONE of the additional services you are requesting:

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 upload a copy of the following documents: PDF, WORD or JPG file format.

Drivers License or State ID

Birth Certificates (For children 15 & Under)

Proof of Income

Utility Bill (Such as Lights, Water, etc)

Additional Upload Space as needed

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

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MUST READ BEFORE SUBMITTING

Submission does not guarantee approval. Upon receipt of required information, your application will be reviewed for possible approval.

For any questions, feel free to contact us at https://www.therjfoundation.com/about or email us at contactrjfoundation@gmail.com