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Humanitarian Assistance Committee - HAC

Humanitarian Request Form

Requester Information:
Requester Name:


Case Information:
Name of Person Family in need*:
Social Security Number:
Date of Birth:


Contact Information:
Telephone:
Email:
Address:	Street:
	Apt:
	City:
	State:
	ZipCode:
References: Give the name and the contact info for 3 references	First Reference: Name: Phone or Email: Second Reference: Name: Phone or Email: Third Reference: Name: Phone or Email:


Case Details:
Case Description:


Current Financial Status:
Number of dependents:
Dependent Description: (age etc)
Monthly Icome* $:
Food Stamps $:
Savings:
Other Icome: (Such as support from other masajid,islamic centers or churches(explain)


Expenses:
Monthly Expenses* $:
Detailed Expenses: (such as rent,electricity ,water, phone,medical ..etc)


Employment:
Currently Working:	Yes No
	If No, last time worked:
Employer Name:
Employer Contact Info:
Request Amount:

	I fully authorize the Austin Humanitarian Assistance Committee (Austin HAC) to conduct any requiered background checking to process this case, inluding but not limiting to contacting the references mentioned above.