Assistance Application |

Applicant Name*

First Last

Today's Date

Current Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Email

Is anyone applying on your behalf?*

Yes
No

Please provide name and phone number of person applying on your behalf.*

Tell us what you need assistance with and why?*

What is your diagnosis?*

Digital Signature*

Applicant Acceptance of below:

I certify that above information along with any attachments are true and complete to the best of my knowledge. I understand that this application must be approved by the majority of the Board of Directors at C.U.C.F and that I (of the person that applied on my behalf) will be notified if approved. I fully understand that this is a one-time donation. I also understand that the donation will be payable to an organization, lender, or company not to me personally.

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Assistance Application

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