EREZ FUND APPLICATION FOR ASSISTANCE
DUE TO THE OVERWHELMING NUMBER OF APPLICATIONS WE HAVE RECEIVED, WE ARE NOT ACCEPTING APPLICATIONS AT THIS TIME. ONCE THE CURRENT APPS ARE FILLED, WE WILL OPEN THE PROCESS AGAIN. THANK YOU FOR YOUR UNDERSTANDING.
01.12.12
Emergency assistance funds are distributed on a first-come basis. Eligibility and assistance donations are a one time payment based upon the number of people in your home, income of everyone in your home, type and cost of heating and where you live. If you are eligible, the payment is made to your supplier. The EREZ Fund currently supports requests having to do with weather related crises.
PLEASE PRINT
Name: ______________________________________________________
Date of birth: ______________________ Age: ___________
Do you have fuel now? ____ Number of people living in the home: ______
Ages of people living in the home: _________________________________
Is anyone over the age of 65? _________
Nature of request for assistance: ___________________________________
RESIDENCE
Delivery Address: ________________________________________________
Name of Reservation, Agency or Territory: ___________________________
Present Telephone number: _______________________________________
Type of heating fuel: _____________________________________________
Fuel Company Address: __________________________________________
Account Number: _______________________________________________
Age of home: ___________
If request is for livestock
Livestock feed: _________________________________________________
Type of livestock: _______________________________________________
Vendor Address: ________________________________________________
INCOME INFORMATION
Monthly household income: $______________
Source of Income: _______________________________________________
REFERRAL
Where did you hear about the Whisper n Thunder EREZ Fund?
_______________________________________________________________
AUTHORIZATION
Signed: ________________________________________________________
Date: __________________________________________________________
Please mail to:
Whisper n Thunder Inc.
c/o Rebecca Balog, EREZ Chair
PO Box 10891
Glendale, AZ 85318
