Need-A-Break Gift Request | The Rescue Mission

Personal Information

How Did You Hear About Us?

First & Last Name

Date Of Birth

Phone Number

Cell Phone Number

Email Address

Street Address (apt or unit #)

City

State

Zip

Please list any disabilities we should be aware of when assessing your need

Financial Information

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

Gift Request Information

Applicants must also separately submit copies of the past two years tax returns/SS statements/pension benefit statements.

Have You Previously AppliedYesNo

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!

Could You Help With The Costs For This Gift?YesNo

Type Of NeedVehicle Repair
Household Needs/Furniture

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

Need-A-Break Program 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 Program 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!

Programs

Facilities

Gift Request

Select All That Apply

Property Information

Vehicle Information