Need A Break Services Gift Application

This gift program aims to assist with one-time needs that will make a meaningful difference for someone who is otherwise able to maintain stability.

This section is for home repair requests only

FORM INSTRUCTIONS: Please fill out application as completely and thoroughly as possible. Leaving out information will cause a delay in the application process. All items with an asterisk (*) are required to be filled out before form can be submitted.

OUR PROGRAM CANNOT HELP WITH EMERGENCY NEEDS OR PAYMENT OF BILLS - THIS INCLUDES RENT, UTILITIES, CAR PAYMENTS, MEDICAL BILLS, ETC. 

​APPLICATION PROCESSING TIMES VARY, AND USUALLY TAKE 1-3 WEEKS DEPENDING ON THE REQUEST DUE TO PROCESSING TIME.

THANK YOU FOR YOUR PATIENCE!
​To download a PDF version of the application to mail or fax in, click here. (online application is preferred)

this section is for vehicle repair requests only

this section is for furniture and household needs requests only

this section is for other requests only