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Need Qualification

This form should only be completed and submitted if your annual family income is within the ranges specified by the US Federal guidelines found at: http://www.fns.usda.gov

Please fill in all fields, then click on Submit Form. All information will be kept strictly confidential by Repair & Share and will not be provided to any other organization or company.

You still must call and make an appointment with Repair and Share and mention your Need Qualification Form so the Form can be matched with the Appointment.

Submitter:
Last Name:

MI:

First Name:

Street Address:

City :

State:

Zip Code:

Home Phone:

Cell Phone:

Gross Annual Income:

Number of dependent children:

Other dependents:
(parents, grandparents, etc.)

Email

You still must call and make an appointment with Repair and Share and mention your Need Qualification Form so the Form can be matched with the Appointment.