The Salvation Army Fond du Lac
Circle of Support Assistance Request
Helping you build a better tomorrow.
(Excluding Ripon, which is served by
The Salvation Army Service Extension
)
Head of Household Name
*
Country
United States
Canada
----------------------
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegowina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, the Democratic Republic of the
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia (Hrvatska)
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and Mc Donald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Republic of
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia, The Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territories
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia (Slovak Republic)
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
St. Helena
St. Pierre and Miquelon
Sudan
Suriname
Svalbard and Jan Mayen Islands
Swaziland
Sweden
Switzerland
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna Islands
Western Sahara
Yemen
Zambia
Zimbabwe
Address
City
,
State
and
ZIP Code
State
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
AA
AE
AP
If you did not list an address above, where did you sleep last night?
In a vehicle
At a friend/relatives temporarily
Outside
In a shelter
Other
Email
Phone Number
What's your preferred method of communication?
*
Email
Phone
Date of Birth
*
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Household Information
Number of Adults in the Household
*
Number of Children in the Household
*
I am currently
*
Employed
Laid Off
Job Searching
Unable to Work
Please select every type of income your household receives:
*
SSI
SSDI
Employment Income
Child Support
Alimony
Unemployment
Commission
Tips
Other
If you selected other, please list
Please describe the struggles you are facing that bring you to us:
*
Are any of your needs due to or related to COVID?
*
Yes
No
If you selected yes, please describe
*
How can we assist?
Please indicate all the types of assistance you are searching for:
*
Rental Assistance
Utility Payment Assistance
Food
Spiritual assistance
Emotional support
Employment search assistance
Case management services
Budgeting assistance
Life Skills Coaching
Peer-to-Peer Support Group
Other
If you selected other, please list
Check All of the Agencies you have requested help from in the past 24 months
*
Energy Assistance
Unemployment
Food Share/SNAP
Temporary Assistance for Needy Families (TANF-W2)
Advocap
St. Vincent DePaul
Solutions Center
Rural Housing
WRAP (Wisconsin Rental Assistance Program)
Forward Services
Center for Veterans Issues
Fond du Lac Co Veterans Dept.
Fond du Lac Co. Health Dept.
Fond du Lac Co. Senior Services
ADRC (Aging & Disability Resource Center)
Legal Action of Wisconsin
City of Fond du Lac
Consumer Credit Counseling
Fond du Lac Housing Authority
CARE Inc.
Other
If you selected other, please list
Check all of the assistance you have received in the past 24 months
*
Energy Assistance
Unemployment
Food Share/SNAP temporary
Assistance for Needy Families (TANF-W2)
Stimulus Check
Advocap
St. Vincent DePaul
Solutions Center
Rural Housing
WRAP (Wisconsin Rental Assistance Program)
Emergency Assistance
Forward Services
The Salvation Army
Center for Veterans Issues
Fond du Lac Co. Veterans Department
Fond du Lac County Health Department
Fond du Lac County Senior Services
ADRC (Aging & Disability Resource Center)
Legal Action of Wisconsin
City of Fond du Lac
Consumer Credit Counseling
Fond du Lac Housing Authority
CARE Inc.
Other, please list below
Other
What additional information would be useful for us to know so we can best serve you?
Disclaimer/Release of Information:
*
I understand that The Salvation Army is committed to do all that they can to develop my capacity for successful living. I give permission to The Salvation Army to collaborate, communicate, and cooperate with other Salvation Army departments and external community resources to provide additional services and resource tools.
I understand that The Salvation Army adheres to The Salvation Army USA's Policy and Guidelines on Confidentiality and the Protection of Personal Privacy.
I understand a Salvation Army employee will reach out to me within the next three business days.
I, the undersigned, agree to the terms above.
Submit
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