Christmas Assistance Application Form

Gathers household, income, and need details from each applicant so a charitable organization can fairly allocate holiday gifts and assistance.

Use this template

Head of Household

Nombre

Apellido

Date of Birth

Gender

Male Female Other

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Email:

Phone Number

Number of People in Your Household:

1st Household Member Name (other than head of household):

Nombre

Apellido

Date of Birth

Relationship to You:

2nd Household Member Name:

Nombre

Apellido

Date of Birth

Relationship to You:

3rd Household Member Name:

Nombre

Apellido

Date of Birth

Relationship to You:

4th Household Member Name:

Nombre

Apellido

Date of Birth

Relationship to You:

First Child: Name

Nombre

Apellido

Date of Birth

Age:

Boy or Girl?

Wish #1:

Wish #2:

Wish #3:

Clothing Size (please indicate if it's a children's or adult size):

Shoe Size (please indicate if it's a children's or adult size):

Second Child: Name

Nombre

Apellido

Date of Birth

Age:

Boy or Girl?

Wish #1:

Wish #2:

Wish #3:

Clothing Size (please indicate if it's a children's or adult size):

Shoe Size (please indicate if it's a children's or adult size):

Third Child: Name

Nombre

Apellido

Date of Birth

Age:

Boy or Girl?

Wish #1:

Wish #2:

Wish #3:

Clothing Size (please indicate if it's a children's or adult size):

Shoe Size (please indicate if it's a children's or adult size):

Fourth Child: Name

Nombre

Apellido

Date of Birth

Age:

Boy or Girl?

Wish #1:

Wish #2:

Wish #3:

Clothing Size (please indicate if it's a children's or adult size):

Shoe Size (please indicate if it's a children's or adult size):

Fifth Child: Name

Nombre

Apellido

Date of Birth

Age:

Boy or Girl?

Wish #1:

Wish #2:

Wish #3:

Clothing Size (please indicate if it's a children's or adult size):

Shoe Size (please indicate if it's a children's or adult size):

Sixth Child: Name

Nombre

Apellido

Date of Birth

Age:

Boy or Girl?

Wish #1:

Wish #2:

Wish #3:

Clothing Size (please indicate if it's a children's or adult size):

Shoe Size (please indicate if it's a children's or adult size):

Income for Head of Household

Nombre

Apellido

Monthly Income Sources

Monthly Salary Amount:

Monthly Public Assistance Amount:

Monthly Food Stamps Amount:

Monthly Rent Paid by Section 8:

Monthly Pension Amount:

Monthly Unemployment Benefits Amount:

Monthly Child Support Amount:

Other Monthly Income Received:

Income for 2nd Adult in Family:

Nombre

Apellido

Monthly Income Sources

Monthly Salary Amount:

Monthly Public Assistance Amount:

Monthly Food Stamps Amount:

Monthly Rent Paid by Section 8:

Monthly SSI/SSD Amount:

Monthly Pension Amount:

Monthly Unemployment Benefits Amount:

Monthly Child Support Amount:

Other Monthly Income Received:

Income for 3rd Adult in Family:

Nombre

Apellido

Monthly Income Sources

Monthly Salary Amount:

Monthly Public Assistance Amount:

Monthly Food Stamps Amount:

Monthly Rent Paid by Section 8:

Monthly Pension Amount:

Monthly Unemployment Benefits Amount:

Monthly Child Support Amount:

Other Monthly Income Received:

Monthly Expenses

Rent/Mortgage:

Gas/Heat/Oil:

Electricity:

Cable/Internet:

Phone

Car Payment:

Car Insurance:

Other Monthly Expenses

Have you already submitted copies of ID for everyone in your household, along with proof of income and expenses? If not, you may be asked to provide these before your application can be processed.

Yes No

Upload copies of any IDs, income, or expense documents we don't already have on file

Max 10 MB per file

Are you requesting assistance from any other organization?

Do you attend church regularly? (this has no effect on your application)

Enter Church Name

Yes

Christmas Assistance Application Form

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