Assistance — MELJ

Do you need assistance?

Name

First Name

Last Name

Phone

(###)

###

####

Alternate Contact (name and number)

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How did you hear of us?

Are you asking for assistance on behalf of someone, or asking for yourself?

Have you been incarcerated? If so, what for?

Date of Incarceration

General dates are fine if you don't know specifics!

YYYY

Date of Release

YYYY

Are you currently on parole or probation? If so, how long?

Do you have any disabilities?

What do you need assistance with?

Assistance is based on need, funds available, and whether you qualify for our assistance program.

Intake fee: $45 for all, except for those who are on parole. You may submit via cashapp at $MELJCenter or Paypal by clicking the donate button.

Please call our office for more information.