Emergency Assistance Application
We only require this statement of need and physician statement.

Date:________

APPLICANTS NAME_________________________DOB__________

ADDRESS__________________________________PHONE________

REASON FOR NEED

Please describe your present situation__________________________________

Have you applied at any other organization?_____If so where?________________

(Applicant, you are also referred to the American Cancer Society at 1-800-ACS2345, to St. Pauls Catholic Church at 287-7601, and CAP at 287-7070)

How many adults in your household?_____ How many children?____

What is your total family income and from what source______________________

What is your most immediate need?_____ Please list in order of importance.

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TYPE OF ASSISTANCE

( ) Food

( ) Transportation

( ) Utilities _____________________ (list only those that haven't been paid)

( ) Mortgage or rent.___________(list the amount that hasn't been paid)

( ) Other, Gas Cards, etc_______________

Comments:______________________________________________________________________________________________________________________________

Applicants Signature___________________________________

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PENDING: Doctors Statement ________________________

(please give an indicator on how many trips you anticipate and the distance per trip.)_______

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Type of Expense___________ Amount Approved________________

Approved by_______________________ Date___________

Mail Application & Statement from Doctor to:
JCCF PO Box 659 Mckee, Ky. 40447