Houston Charity Center Assistance Program
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Recipients are responsible for arranging their own transportation/delivery to and from 4209 Spencer Hwy, Pasadena TX, 77504 -
Assistance is limited to 1 time per year.
Select
the
services you are in
emergency need
of.
Food
Clothing
Furniture (Furniture MUST be picked up the SAME DAY the voucher is used)
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I consent to my personal information being shared with the donor whose contribution made this assistance available.
Yes
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First Name
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Last Name
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Social Security Number
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Address (If Homeless, write NO ADDRESS in the field provided)
Address 2
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Telephone Number
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City
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State
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Zip
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Email Address
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ALL 3 questions must be answered in full.
1.
Provide a complete description of your situation.
2.
What happenend to cause your present cicumstances.
3.
Describe how we might be able to verify your situation for our records.
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List the name, relation and age of each individual residing at your address.
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What steps are you taking
to help yourself
gain or regain stability? Please take a moment to consider your answer carefully.
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Indicates Response Required