Matrix Community Outreach Center Assistance Form

What assistance are you requesting (your most immediate need)?*
Explain Other
Number of Children
Each 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/MI
Email
Date of Birth*
Date Format: MM slash DD slash YYYY
Gender*
Family Status*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Alternative Phone
Ethnicity
Additional Persons in Household
Additional person 1
Person 1-First Name
Child 1-First Name
Last Name
Child 1-Last Name
Date of Birth*
Date Format: MM slash DD slash YYYY
Gender
Grade
Relationship
Items of interest
Please 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 2
Person 2-First Name
Child 2-First Name
Last Name
Child 2-Last Name
Date of Birth*
Date Format: MM slash DD slash YYYY
Gender
Grade
Relationship
Items of interest
Please 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 3
Person 3-First Name
Child 3-First Name
Last Name
Child 3-Last Name
Date of Birth*
Date Format: MM slash DD slash YYYY
Gender
Grade
Relationship
Items of interest
Please 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 4
Person 4-First Name
Child 4-First Name
Last Name
Child 4-Last Name
Date of Birth*
Date Format: MM slash DD slash YYYY
Gender
Grade
Relationship
Items of interest
Please 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 5
Person 5-First Name
Child 5-First Name
Last Name
Child 5-Last Name
Date of Birth*
Date Format: MM slash DD slash YYYY
Gender
Grade
Relationship
Items of interest
Please 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 6
Person 6-First Name
Child 6-First Name
Last Name
Child 6-Last Name
Date of Birth*
Date Format: MM slash DD slash YYYY
Gender
Grade
Relationship
Items of interest
Please 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 7
Person 7-First Name
Child 7-First Name
Last Name
Child 7-Last Name
Date of Birth*
Date Format: MM slash DD slash YYYY
Gender
Grade
Relationship
Items of interest
Please 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 8
Person 8-First Name
Child 8-First Name
Last Name
Child 8-Last Name
Date of Birth*
Date Format: MM slash DD slash YYYY
Gender
Grade
Relationship
Items of interest
Please 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 9
Person 9-First Name
Child 9-First Name
Last Name
Child 9-Last Name
Date of Birth*
Date Format: MM slash DD slash YYYY
Gender
Grade
Relationship
Items of interest
Please 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*
NON-EXPIRED ID FOR ALL ADULTS IN THE HOUSEHOLD*
BIRTH CERTIFICATES OR IMMUNIZATION RECORDS FOR CHILDREN
SOCIAL SECURITY CARDS FOR ALL IN HOUSEHOLD*
Drop files here or
CHECK STUBS FOR LAST 30 DAYS
FOOD STAMPS ELIGIBILITY LETTER
SSI/SSDI/SOCIAL SECURITY STATEMENT
CHILD SUPPORT DOCUMENTS
BILLS (PAID, UNPAID, RECEIPTS, i.e. WATER, ELECTRIC, GAS, CABLE, INTERNET, CAR INSURANCE, CAR PAYMENT) –*
ΜΟSΤ RΕCΕΝΤ ΒΑΝΚ SΤΑΤΕΜΕΝΤ
MOST RECENT BILL YOU NEED ASSISTANCE WITH (MUST BE DISCONNECT NOTICE SHOWING PAST DUE AMOUNT) BILL IN YOUR NAME
MORTGAGE/LEASE IN ADDITION TO SECTION 8/HUDIF APPLICABLE (Must have a yearly Lease)
FOR RENTAL ASSISTANCE MUST HAVE THREE DAY EVICTION NOTICE
FOR 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 Name
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Comments
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