Emergency Assistance Application

Please fill in as many fields as possible and click the SUBMIT button at the bottom of the page. All information is confidential and will be used for Take The Lead purposes only.

Please note that this program is to be used exclusively for civil disasters. If you are need of assistance with a life-threatening or terminal illness, please click here.

(Note that information entered into this form is protected by a secure Internet connection using 128 bit encryption to protect the privacy and security of your information.)

PERSONAL

REFERENCES

INVOLVEMENT

BILLS

ACCEPTANCE – I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT. I UNDERSTAND THE FOLLOWING: 1) THE INFORMATION IS BEING GIVEN IN CONNECTION WITH SERVICES PROVIDED. 2) THE TAKE THE LEAD ASSISTANCE ADMINISTRATION COMMITTEE MAY VERIFY THE INFORMATION GIVEN ON THIS FORM. 3) IF I DELIBERATELY MISREPRESENT INFORMATION ON THIS APPLICATION, I AGREE TO REPAY BENEFITS PROVIDED BY TAKE THE LEAD, INC. AND I MAY BE PROSECUTED UNDER THE APPLICABLE STATE AND FEDERAL STATUTES.

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