GCR Good Neighbor Assistance Request

Please fill out the form below with as much detail as possible to request assistance. We will review all requests in the order they are received. If you do not hear back from us within 3-4 business days, please contact 211 for a list of other agencies that might be able to assist you. Submitting this form does not guarantee assistance. Incomplete forms will not be processed or considered. By submitting this form, you give permission for information to be shared and obtained from other agencies, landlords, apartment managers, utility companies, the Charity Tracker Database, etc.

Your name *

Email address *

If you are filling this form out on behalf of someone else, please put your name and contact information here.

Phone number *

Address *

Birthdate *

Last four digits of your social security number. *

Did a GCR member refer you? If yes, who?

Did another organization refer you to GCR? If yes, who?

Please list all children and adults who live with you as well as their ages and relationship to you. *

Where are you currently employed?

What is your current monthly household income?

What kind of assistance are you requesting?

Amount Requested

Please list any assistance you are currently receiving and from where.

All applicants will be run through Midland Charity Tracker to see other assistance that area organizations have provided. Submitting this form also allows GCR to update information within Charity Tracker.

Please explain, in detail, the reason you are requesting help.

Upload any supporting documents here (lease agreement, bills, etc.) Applications submitted with no supporting documents will not be considered.

No files currently selected

Add up to 5 files. Maximum file size 10 MB.

If needed, please e-mail any supporting documents (lease agreement, bill, etc.) to ryan.rampton@gcrcc.org.

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