Christmas Benefit Request Form

REQUEST FOR FINANCIAL ASSISTANCE FROM

THE RIVER RATS, INC.

Name of Member who told you about River Rats Assistance: ____________________________

Date of Request: _________________

Is the individual in need of help a relative of yours? Yes No

Name and address of individual in need:

_______________________________________
_______________________________________

Phone Number:____________________________

What are the circumstances of their need? Please describe in as much detail as you can. Attach any additional documentation you have. ________________________________________________________________________________________________________

________________________________________________________________________________________________________

Children:

Full Name                                         Age             School

____________________ ____ ______________________

____________________ ____ ______________________

____________________ ____ ______________________

____________________ ____ ______________________

Is “time of the essence”? Is it needed before the next meeting (why?) or can it wait for review by the board at that time? __________________________________________________________________

What other avenues of assistance are being pursued? /Granted?

___________________________________________________________________

Have they ever received any prior assistance from the River Rats? If yes,

Describe:_____________________________________________________________

How much are you requesting that the River Rats donate? ____________________________________________________________________

In what format do you suggest the donation be made? i.e. payment directly to the power company, Mortgage Company, or gift certificate to Wal-Mart, Lowe’s, Food Lion, etc.

____________________________________________________________________

I authorize the River Rats to verify the information I have provided.

Signed____________________________________Date________________________

Written forms must be received by the River Rats by 3:00pm Friday, December 4, 2011 at

PO Box 567

Southmont, NC 27351