Name: Franklin Community Center
Address: 10 Franklin Street, Saratoga Springs, NY, 12866, US
Telephone: +15185879826

Name*
Phone*
Email*
Address*
Street Address City State ZIP Code
Please list all adults over 18 that live in your household permanently (including yourself):*
First name Last Name Date of Birth
Please list all children under the age of 18 that live in your household permanently*
First name Last Name Date of Birth School Proof of Residency
Please select your race*
- Asian
- Black/African American
- Hispanic
- White
- Other
Please circle your yearly income level*
- under $13,000
- $13,000-$23,000
- $23,001-$33,000
- $33,001-$43,000
- $43,001-above
Have you or do you plan to apply to receive holiday assistance from any other agency this year?*
- Yes
- No
If yes, what is the name of the agency?
Franklin Community Center, Inc. will be checking with all other agencies to verify that you are not receiving assistance from any other group. You are hereby authorized to furnish and release any and all information and records that are requested by Franklin Community Center, Inc. and give Franklin Community Center, Inc. permission to discuss this application with other agencies as necessary. If we find that you are dishonest in your application in any way or have applied elsewhere for assistance, you will be ineligible for assistance at any agency.

Holiday Assistance Application

Child 1

First name	Last Name	Date of Birth

First name	Last Name	Date of Birth	School	Proof of Residency