REJOYCE NOW | REJOYCE MINISTRIES

REJOYCE NOW
Basic Needs Intake Form

If you are a North Carolina resident who is facing challenges with access to adequate food, stable housing or general resources, you are encouraged to complete this form. This form will be assessed to provide individual resource suggestions and options for additional resources that may be able to meet your need. Please note this application is not a guarantee for assistance but we will do everything within our capacity to assist the need. There may be times when you are required to have a portion of the amount needed (particularly for utilities) as we may not have the funding to pay your entire bill. We ask that you remain respectful and only request what you need. Others also have needs, and we want to do the best we can to meet as many needs as possible.

First Name

Last Name

Address (street, apt/suite)

City, State & Zip

Birthdate

Gender

# Adults in Household

# Children in Household

I need help with the following* (please select one): Required

Grocery

Utility Payment (provide details below - assistance paid directly to the service provider

Temporary Hotel Stay (2 day max) - assistance paid directly to approved hotel

Bus Pass

Gas Card

Hot Meal

Other (please be specific in details section)

Account #

Utility Service Provider/Hotel Name

Provider Contact Number

Please include detailed description of need.

Requirements for consideration

For Temporary Hotel Stay, you must provide notice of eviction
In order to request assistance for utilities you must provide the following: service provider, the name the utility is in (details if not in your name), the past due amount, your account information and a disconnect notice
Applicants/households are only allowed to use our services twice in any calendar year AND there is a minimum 30 day waiting period from the last time assistance was received from our organization
Please allow 2-3 business days for a response from a REJOYCE NOW, Inc, team member. If you do not receive a response after the 3rd business day, please feel free to send a message via our website www.mindebb.com
Please seek other resources in addition to us as we cannot guarantee services. Approval is on a case by case basis.
There will be no money exchanging hands, our services are provided through gift cards or paying providers directly.
At this time REJOYCE NOW, Inc, has a maximum award of $200 per family per payout.

Approved

Denied

Assistance Provided

Amount Approved

Date approved

Approved by

Thanks for submitting!

Reason for Approval/Denial

Date Approved

REJOYCE NOW Basic Needs Intake Form

REJOYCE NOW
Basic Needs Intake Form