Matrix Community Outreach Center Assistance Form What assistance are you requesting (your most immediate need)?*Choose OneClothingFoodFood stamps/MedicaidGas/FuelHousehold ItemsHousingRental/MortgageTransportationUtilitiesOtherExplain OtherNumber of ChildrenNone123456789Each child must be listed with first name, last name, gender, and age.Date* Date Format: MM slash DD slash YYYY Last Name*First Name*Maiden/MIEmail Date of Birth* Date Format: MM slash DD slash YYYY Gender*ChooseFemaleMaleFamily Status*ChooseMarriedNever MarriedWidowedDivorcedSeparatedAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Alternative PhoneEthnicityChooseBlackHispanicNative AmericanWhiteOtherAdditional Persons in HouseholdNone123456789Additional person 1Person 1-First NameChild 1-First NameLast NameChild 1-Last NameDate of Birth* Date Format: MM slash DD slash YYYY GenderChooseFemaleMaleGradeRelationshipItems of interestPlease give us three areas of interest for the child. Sports, Hunting, Fishing, Bicycling, Gators, Seminoles. This is information we will use when matching gifts.Additional person 2Person 2-First NameChild 2-First NameLast NameChild 2-Last NameDate of Birth* Date Format: MM slash DD slash YYYY GenderChooseFemaleMaleGradeRelationshipItems of interestPlease give us three areas of interest for the child. Sports, Hunting, Fishing, Bicycling, Gators, Seminoles. This is information we will use when matching gifts.Additional person 3Person 3-First NameChild 3-First NameLast NameChild 3-Last NameDate of Birth* Date Format: MM slash DD slash YYYY GenderChooseFemaleMaleGradeRelationshipItems of interestPlease give us three areas of interest for the child. Sports, Hunting, Fishing, Bicycling, Gators, Seminoles. This is information we will use when matching gifts.Additional person 4Person 4-First NameChild 4-First NameLast NameChild 4-Last NameDate of Birth* Date Format: MM slash DD slash YYYY GenderChooseFemaleMaleGradeRelationshipItems of interestPlease give us three areas of interest for the child. Sports, Hunting, Fishing, Bicycling, Gators, Seminoles. This is information we will use when matching gifts.Additional person 5Person 5-First NameChild 5-First NameLast NameChild 5-Last NameDate of Birth* Date Format: MM slash DD slash YYYY GenderChooseFemaleMaleGradeRelationshipItems of interestPlease give us three areas of interest for the child. Sports, Hunting, Fishing, Bicycling, Gators, Seminoles. This is information we will use when matching gifts.Additional person 6Person 6-First NameChild 6-First NameLast NameChild 6-Last NameDate of Birth* Date Format: MM slash DD slash YYYY GenderChooseFemaleMaleGradeRelationshipItems of interestPlease give us three areas of interest for the child. Sports, Hunting, Fishing, Bicycling, Gators, Seminoles. This is information we will use when matching gifts.Additional person 7Person 7-First NameChild 7-First NameLast NameChild 7-Last NameDate of Birth* Date Format: MM slash DD slash YYYY GenderChooseFemaleMaleGradeRelationshipItems of interestPlease give us three areas of interest for the child. Sports, Hunting, Fishing, Bicycling, Gators, Seminoles. This is information we will use when matching gifts.Additional person 8Person 8-First NameChild 8-First NameLast NameChild 8-Last NameDate of Birth* Date Format: MM slash DD slash YYYY GenderChooseFemaleMaleGradeRelationshipItems of interestPlease give us three areas of interest for the child. Sports, Hunting, Fishing, Bicycling, Gators, Seminoles. This is information we will use when matching gifts.Additional person 9Person 9-First NameChild 9-First NameLast NameChild 9-Last NameDate of Birth* Date Format: MM slash DD slash YYYY GenderChooseFemaleMaleGradeRelationshipItems of interestPlease give us three areas of interest for the child. Sports, Hunting, Fishing, Bicycling, Gators, Seminoles. This is information we will use when matching gifts.Annual Household Income*0-12,70012,701-17,24017,241-21,72021,721-26,20026,201-30,68030,681-35,16035161-3964039641-44120NON-EXPIRED ID FOR ALL ADULTS IN THE HOUSEHOLD*BIRTH CERTIFICATES OR IMMUNIZATION RECORDS FOR CHILDRENSOCIAL SECURITY CARDS FOR ALL IN HOUSEHOLD* Drop files here or CHECK STUBS FOR LAST 30 DAYSFOOD STAMPS ELIGIBILITY LETTERSSI/SSDI/SOCIAL SECURITY STATEMENTCHILD SUPPORT DOCUMENTSBILLS (PAID, UNPAID, RECEIPTS, i.e. WATER, ELECTRIC, GAS, CABLE, INTERNET, CAR INSURANCE, CAR PAYMENT) –*ΜΟSΤ RΕCΕΝΤ ΒΑΝΚ SΤΑΤΕΜΕΝΤMOST RECENT BILL YOU NEED ASSISTANCE WITH (MUST BE DISCONNECT NOTICE SHOWING PAST DUE AMOUNT) BILL IN YOUR NAMEMORTGAGE/LEASE IN ADDITION TO SECTION 8/HUDIF APPLICABLE (Must have a yearly Lease)FOR RENTAL ASSISTANCE MUST HAVE THREE DAY EVICTION NOTICEFOR PRESCRIPTION ASSISTANCE MUST HAVE PRINT OUT OF PRESCRIPTION COST FRΟΜ WΑLGRΕΕΝS ΡΗΑRΜΑCΥ. WΕ DΟ ΝΟΤ ΑSSΙSΤ WΙΤΗ ΑΝΥ ΝΑRCΟΤΙCS.ΡRΟΟF ΟF ΗΑRDSΗΙΡ: Hardship must not be ongoing, a temporary bump in the road, and must have occurred in the last 45 days… NO EXCEPTIONS! LETTER FROM EMPLOYER LOSS OF JOB OR NEW HIRE LETTER CHECK STUBS SHOWING LOSS OF HOURS/WAGES REFERRAL LETTER FROM ANOTHER AGENCY STATING YOU NEED ASSISTANCE Etc DOCTOR'S NOTE STATING INABILITY TO WORK UNEMPLOYMENT PAPERWORK (CONFIRMATION PAGE, DENIAL OR APPEALS LETTER) HARDSHIP FORMS REFER TO EXAMPLES ABOVE Drop files here or Consent I have read and understand the above.The Matrix is a social service administrator, here to advocate on your behalf. We are partnered with others to maximize services available to all. We provide services based on availability which changes daily. A large portion of our resources come from outside partners’ therefore processing takes time and funding is limited. Date Date Format: MM slash DD slash YYYY Your NameCAPTCHANameThis field is for validation purposes and should be left unchanged.