Please fill out the form below and press the “Submit Application” button when completed.
As an alternative you may download a Word form (click here to download the Word form) and mail it, or send it as an e-mail attachment.

‘ONE CAN HELP’ ASSISTANCE APPLICATION

What type of help are you requesting?

What problem is your client facing that makes this request necessary? (Within the rules of confidentiality, please be as specific a possible while describing the issues facing your client.)

The cost of this is approximately:
Date this assistance is needed by (if known):

Please indicate what other attempts have been made to secure this item or service:

How is it anticipated that this assistance from One Can Help will help your client?

Are you willing to work with our representatives to help your client receive our assistance?
   Yes     No

Are you willing to provide information in the future to our organization so that we may ascertain how this assistance has benefited your client?
   Yes     No

Name of person making request:
Your professional relationship to the client:
What court is your client involved with?
Best telephone number to reach you:
Your E-mail address:

Any additional information about this request that might be helpful for us to know:

Please note that this organization is run entirely by volunteers. If you don't hear from us within 5 business days please contact us again.

    

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