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United Women of Rockland
Application for Assistance
Name
Address
Phone
Email
Date of Birth
Employed By
Last Day of Employment
Est. Monthly Medical Expenses
Insurance Coverage
Yes
No
Own/Rent home
Monthly Payment
Missed Payments
Yes
No
Monthly Utilities
Missed Utilities Payments
Yes
No
Provide additional information you feel is important
Do you receive any assistance from Family
Please List Family Members and their ages living in the home
Description of Illness
Date of Onset
Description of Need
Submit
Thanks for submitting!
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