Please use this form to determine what help you need from ACT Lawrence.

Please know that we are assisting clients on a first-come, first-served basis, so we ask that you be patient.

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* 1. What help do you need from ACT Lawrence during this crisis?

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* 2. Full name

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* 3. Phone number

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* 4. Address:

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* 5. What is your date of birth?

Date

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* 6. Marital Status:

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* 7. Total household size:

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* 8. Are you? (check all that apply)

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* 9. Are you?

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* 10. What is your household annual income?

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* 11. This agreement releases ACT Lawrence from all responsibility related to the help I am receiving. By signing this agreement, I agree to keep ACT Lawrence completely free of any liability, including financial responsibility for the consequences incurred.

I, as a customer, fully understand and accept the above terms.

I accept my responsibilities in the use of electronic signatures as described in this form

Please write your full name below

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