Need A Break Services Gift Request Form To download a printable version of the form, click here. Need-A-Break Services is unable to help with utility and rent bills or any other recurring expense Applicant must be 18 years or older and have a need that they cannot fulfill on their own PERSONAL   Date: How did you hear about us? (if you heard about us from a friend, please provide a name) Your full name (first, middle, and last): Your date of birth: Phone number: Cell Phone Email: Home address: City: State: Zip: Please list any disabilities we should be  aware of when assessing your need   Select all that apply: I am elderly I am disabled    I am a single working parent My family is facing an unexpected hardship I recently escaped homelessness I recently escaped domestic violence   Are you a United States citizen? Yes          No What is your race/ethnicity? African American Asian/Pacific Islander Hispanic Native American Caucasian Do you own your home? Yes          No How long have you lived at this address? Household size : Number of adults in home Number of adults working Number of children in home   FINANCIAL     Employer's Name Employer's Phone  Total household income  per month Other assets or accounts  (autos, bank accounts, etc) Value of other assets  Please list any unusual expenses    :   REQUEST     Applicants must also separately submit copies of the past two years tax returns/SS statements/pension benefit statements. Have you previously applied to Need-A-Break for a gift? Yes          No   Select ONE OPTION of the type of need you have from the categories below and explain in detail Minor Home Repair Wish List - paint touch up, minor roof repair, etc.   Explain home repair wishes in order of priority, including cost of fulfilling need PROPERTY INFORMATION   Number of bedrooms  Number of baths  Type of heat  Electric Gas Propane Oil Other Hot water heated by  Electric Gas Other Home owners insurance company  Policy number  Yard Services Wish List - weeding, planting, brush cleanup, etc. Explain suspected vehicle problem, including cost of fixing vehicle (must be minor=under $300 in cost) 2-3 estimates will need to be turned in final submission Vehicle Year Vehicle Make Vehicle Model   Chores Wish List - organizational project, furniture moving, etc. List and describe items requested, which may include furniture, chores, or other items, including cost of fulfilling need if applicable Other Explain need, including cost of fulfilling need   FOR ALL REQUESTS: Explain why gift is necessary-tell us why you need this help, how this will make a difference in your life and help you succeed!    REFERENCE INFORMATION*     Name of relative or friend not living with you  Relationship to you  Phone number  City/State    Name of relative or friend not living with you  Relationship to you  Phone number  City/State    Could you help with the costs for this gift in any way?  Need-A-Break Services works closely with partner organizations in the community in order to serve our applicants best. We may share information from your application with another nonprofit organization if needed. Please select the button below to show that you understand and allow this (not selecting this may delay or cancel your application): I give Need-A-Break Services permission to release my information to its partner organizations if it is necessary and beneficial   NOTICE: LEAVING ANY PART OF THIS APPLICATION BLANK OR INCOMPLETE WILL DELAY THE APPLICATION PROCESS. DO NOT PRESS THE 'SUBMIT' BUTTON UNLESS YOU HAVE FILLED OUT ALL OF THE APPLICATION! Need-A-Break Services cannot guarantee services will be granted, and all work requested may not be able to be completed on day of work   *References may be called regarding this application