Assistance NEED ASSISTANCE P2G Assistance Application Form All fields are required How Did You Hear About P2G? Social MediaInternetOther [checkbox* marital-status "Single" "Married" "Divorced" "Widowed""] Language: EnglishEspañol I Need Assistance With: ElectricityGasWaterRentOther Amount: I certify that I will not withhold any information that would unfavorably affect my application to receive assistance from Passion2Give. I understand that information contained on my application will be verified by Passion2Give, and any misrepresentation(s) may be cause for my immediate rejection to receive assistance from Passion2Give. I AgreeI Disagree Rights and Waiver I hereby authorize Passion2Give to photograph, take videos, and/or interview me if necessary. I AgreeI Disagree Electronic Signature: (Please type full name) Date: Δ
