CACM Crisis Assistance Form
Connellsville Area Community Ministries provides various types of assistance to families who are in a time of crisis. The Ministry can provide various types of assistance to any family who is currently living in the Connellsville Area School District. Due to limited funding, we are only able to help each family once in a 12-month period. All clients must meet organizational and federal guidelines to qualify for crisis assistance.
Name/Head of Household
Social Security Number
State / Province / Region
Postal / Zip Code
Black or African American
Two or more
Other Members of Household
Number of Other Adults (over 18, including Spouse/Partner)
Names of Other Adults
Number of Children (under 18)
Names of Children
Please fill out this section to the best of your ability.
Total Monthly Income (from everyone in household)
Income Sources (check all that apply by holding down the Ctrl key when clicking)
Do you receive Food Stamps
Total Monthly Expenses
I am seeking help with:
Utility Shut Off
What crisis occurred that you need assistance?
By submitting this form, CACM has my permission to contact all sources necessary to confirm the information on my request.
I certify that all of the above information is correct.
I understand that CACM is not committed to my request. If assistance is provided no guarantee if implied.
Please enter the text from the image: