P.O. Box 4418
Traverse City, MI 49684
Phone:
231-252-4667
Email:
keystofreedomministries@gmail.com
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Assistance Request Form
Assistance Request Form
Assistance Request Form
PERSON REQUESTING ASSISTANCE
Name
*
Phone
*
Email
*
Date
*
REENTRY STATUS (CONFIDENTIAL)
On Probation/Parole?
*
Yes
No
Release Date (incarceration/rehab)
Working with PO/case manager?
*
Yes
No
Name and contact info of PO/Case Manager
If Yes, which Agency?
If Yes, who is your contact?
Type of Assistance Requested
*
Gas
Housing
Transportation
Food
Car
Phone
One Time Rental Assistance
Other
To be eligible for a phone you much be on Probation/Parole and released within 14 days.
If Other, what Assistance are you requiring
Details of Request
*
Amount Requested
*
$
Description of Need/Situation
*
Are you pursuing Other Resources?
*
Resilience Program
Goodwill
Safe Harbor
Other
If Other, what other Resources?
Submission does not guarantee assistance.
KTF Office Use ONLY
PAYMENT INFORMATION
Pay vendor directly?
*
Yes
No
If Yes, which Vendor?
PHONE / MINUTES TRACKING
Phone Issued
*
Yes
No
IMEI #
Card #
BATA Issued
*
Yes
No
If Yes, what is your ID #
Gas Card Issued
*
Yes
No
Phone Eligibity
*
On probation/parole
Released with 14 days (incarceration/rehab)
Approved by
*
Amount
*
$
Date
*
Submit
If you are human, leave this field blank.
