Initial Application Basic Information Love INC is not an emergency service. We believe in taking time to hear your story and problem-solve with you. Part of the Love INC process is the verification of information shared. When contacted by Love INC, please be prepared to engage in the process. Form submissions are sent over a SSL encrypted connection. Date* First Name* Middle Name* Last Name* Date of Birth* Phone Number* To be able to assist you, we must be able to contact you by phone. Message Phone If your phone is not reliable or if you have a secondary number we can reach you at, please provide a message number. To be able to assist you, we must be able to contact you by phone. Physical Address*Where do you live? Please include street name, number, city, and zip code. Have you ever contacted Love INC before?* No Yes Referral If you're a new client, how did you hear about Love INC? Assistance Request Please indicate what you are seeking assistance for. There are no guarantees Love INC will be able to assist with your request(s). Financial Request Car Repair Home Repair Mattress or Used Appliance Purchase Water Bill Other Love INC's financial assistance is limited to $100 per year per household if approved. All financial requests require verification. Non-Financial Request Baby Essentials (children under 24 months) Bus Passes Eyecare Food Gas Card Household Furniture/Appliances Kitchen Essentials Medical Supplies/Home-Health Supplies Minor In-home Repairs Moving Assistance Personal/Household Essentials Ride to Appointment Thanksgiving Work-Required Footwear (work boots, non-skid, athletic) Almost Done! The information provided in the following questions allows Love INC to better assist you with your request(s). How do you get around?* I get rides from family I get rides from friends I have a vehicle I ride public transportation Other If approved, some Love INC assistance will require you to travel to an appointment within our Partner Church Network. If applicable, select more than one. What is your housing situation?* I am homeless I own I rent I stay with someone What is your employment situation* I am disabled I am employed I am retired I am unemployed and not seeking I am unemployed and seeking Please leave this field blank.
Love INC is not an emergency service. We believe in taking time to hear your story and problem-solve with you. Part of the Love INC process is the verification of information shared. When contacted by Love INC, please be prepared to engage in the process.
Form submissions are sent over a SSL encrypted connection.
Date*
First Name*
Middle Name*
Last Name*
Date of Birth*
Phone Number*
To be able to assist you, we must be able to contact you by phone.
Message Phone
If your phone is not reliable or if you have a secondary number we can reach you at, please provide a message number. To be able to assist you, we must be able to contact you by phone.
Physical Address*
Where do you live? Please include street name, number, city, and zip code.
No
Yes
Referral
If you're a new client, how did you hear about Love INC?
Please indicate what you are seeking assistance for. There are no guarantees Love INC will be able to assist with your request(s).
Car Repair
Home Repair
Mattress or Used Appliance Purchase
Water Bill
Other
Love INC's financial assistance is limited to $100 per year per household if approved. All financial requests require verification.
Baby Essentials (children under 24 months)
Bus Passes
Eyecare
Food
Gas Card
Household Furniture/Appliances
Kitchen Essentials
Medical Supplies/Home-Health Supplies
Minor In-home Repairs
Moving Assistance
Personal/Household Essentials
Ride to Appointment
Thanksgiving
Work-Required Footwear (work boots, non-skid, athletic)
The information provided in the following questions allows Love INC to better assist you with your request(s).
I get rides from family
I get rides from friends
I have a vehicle
I ride public transportation
If approved, some Love INC assistance will require you to travel to an appointment within our Partner Church Network. If applicable, select more than one.
I am homeless
I own
I rent
I stay with someone
I am disabled
I am employed
I am retired
I am unemployed and not seeking
I am unemployed and seeking