If you are in need of temporary assistance, please fill out the form below.  Please note that we do not provide monetary assistance. 

All information submitted through this form will remain 100% confidential. The information requested is used only to screen applicants for assistance through Lighthouse Charities. 

Name *
Name
Phone *
Phone
What do you need assistance with? (Check all that apply) *
**Lighthouse Charities DOES NOT provide cash assistance**
Do you receive any other type of federal/state assistance? *
(Check all that apply. If this question does not apply to you, select "none".)