Part One – Head of Household Information
Name
*
First Name
Middle
Last Name
Mailing Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Street Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Home Phone
*
Alternate Phone
Part Two – Assistance information
Please check by the assistance you are requesting
*
Food
Clothing
School Supplies
Diapers
Formula
Feminine Hygiene Products
Soap
Toothpaste
Shoes
Please select one for the size
*
Child
Adult
Write size
*
Other:
Part Three – Declaration of Agreement
By my signature I certify that:
Only one application has been submitted for my household.
All information I have provided regarding my application for KTSU Cares Assistance is true and correct to the best of my knowledge.
Applicant Signature
*
Date
Date Format: MM slash DD slash YYYY