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Community Assistance

"Small acts can take someone a long way."

Community Assistance Form

Please fill out the information below. All requests are kept confidential and reviewed by an Acts of Kindness Merced volunteer.

Program Notice: Acts of Kindness Merced provides limited, needs-based assistance to individuals and families facing an immediate hardship. Assistance may be provided through a gift card or direct payment to a vendor. Cash is never provided. Completing this form does not guarantee assistance.

Applicant Information

Date *

Full Name *

Street Address *

Apartment / Unit (if applicable)

City *

ZIP Code *

Phone *

Email (if available)

Preferred Contact *

Call Text Email

Current Living Situation

Where did you sleep last night? *

Outside Vehicle Emergency Shelter Staying with Friends/Family (temporary) Motel/Hotel Permanent Housing Other

How many people are in your household? *

Are there children in the household? *

Yes No

Assistance Requested

What do you need today? (support comes in the form of gift cards, check all that apply) *

Gas Card Bus Pass/Ticket ID or Document Fee Work-Related Expense School-Related Expense Hygiene/Essential Items Other

Estimated Amount Needed *

Vendor or Store (if known)

Tell Us About Your Need

What happened that created this need? *

How will this assistance help you?

Verification

Have you received this same assistance from Acts of Kindness Merced before? *

Yes No

Have you applied for or received help for this same expense from another organization? *

Yes No

Do you have documentation (bill, estimate, application fee, etc.)? *

Yes No

Certification

I certify that the information provided is true and complete to the best of my knowledge. I understand that assistance is based on verified need, available funding, and program guidelines. I understand that submitting this request does not guarantee assistance and that cash assistance is not provided.

I certify the above statement is true. *

Applicant Signature (type your full legal name to sign electronically) *

Date *

How did you hear about us? (optional)

Need help urgently or don't have internet access to fill this out yourself? Email us at aokmerced@gmail.com or have a friend, case worker, or shelter staff submit this form on your behalf.

Acts of Kindness Merced · Serving Merced, California