General Assistance Reporting

(870) 563-6662

(870) 563-6662

I, *

do confirm that I give general financial assistance to resident

Name *

Of Address *

in the Amount of $ *

each week / month (select one only) *

This financial assistance will be continued until such time as the above-named resident becomes self-sufficient.

In the event the above-named resident does become self-sufficient, and this general financial assistance is discontinued, we both agree that it will be reported to the Housing Authority within ten (10) calendar days.

Dated this: *

SIGNED:

Provider of Assistance *

Tenant *

PROVIDER CONTACT INFORMATION:

Address *

City *

State *

Zip *

Telephone *

Phone *

Message *

Email *

PROVIDER INCOME INFORMATION:

Employer *

City *

State *

Zip *

Telephone *

Point of Contact *