APPLICANT'S NAME:

ADDRESS:

PHONE #: EMAIL ADDRESS:

FIRST AND LAST NAMES OF CHILDREN LIVING AT THE ABOVE RESIDENCE:

Full Name: _________________________________________________ Age: __________ Full Name: _________________________________________________ Age: __________

Full Name: _________________________________________________ Age: __________ Full Name: _________________________________________________ Age: __________

Full Name: _________________________________________________ Age: __________ Full Name: _________________________________________________ Age: __________

3.A. ARE ANY OTHER AGENCIES PROVIDING CHRISTMAS GIFTS FOR YOUR FAMILY OR CHILD?

YES _______ NO _______

*IF YES, WHAT AGENCY: ________________________________________________

3.B. PLEASE INITIAL THE APPROPRIATE LINE…ONLY INITIAL ONE:

3.C. My signature below certifies that all information on this application is true and that all income is reported.

Signature of adult Today's date

SECTION 1 Contact Information / Household Members

(Proof of Residency must be included with this application i.e. current utility bill, pay stub, lease agreement, etc.)

Sometimes children in the household earn or receive income (i.e., earnings from work, social security, income from person outside the household). Please include the TOTAL income received by all children

listed in Section 1 here: