Applications

/files/Images/Logos/LifeServicesLogo.png
Life Services Center
Emergency Services Application



        Applicant Name: Spouse
                  
                    Address:

                       Phone: Email:

                          City: State: Zip:

Place of Employment: Phone: Cell:

Household Information (Including Applicants)

Name (Last, First)                        Age              Relationship             Yearly Income           Source
                               

                               

                               

                               

Total Household Income:

Assistance Needed:         Food/Water        Housing      Clothing

        RLIC Member?          Yes No If No please fill out the information below.

Church Affiliation (Name):
             
              Church Address: Phone:

            Hardships:          Unemployment Death Sickness Disability

Brief Description of Situation:

              Date of Application:

Terms & Conditions
  • Request form must be completed and approved.
  • Eligibility based on program requirements.
  • Benefits determined by family size and available resources.
  • Emergency benefits must not exceed twice within a 12 month period.
  • Allow seven days for response/ Arrangements must be made for pick-up or delivery.
                         


Enter the numbers as they
are shown in the image above

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