KPIF Application

Application For Assistance
Read carefully prior to submitting your application.

KPIF has a hygiene bank, feminine hygiene bank. cleaning supplies, diaper bank, formula bank, small housewares, all things for babies and some furniture. *We do not help with money, bills or food.* We can give resources for those items. All applicants are screened . You must be able to show proof of employeement, disability or have a referal from an agency. If approved, recipients have FIVE DAYS to pick up items or they will be returned to stock. You will need to make arrangements to pick your items up. *We DO NOT guarantee that we can help you or that we have the item you need.* KPIF also reserves the right to make the decision of who we will or will not help. KPIF only assists with basic survival needs to individuals who are experiencing a temporary hardship or crisis. Upon request we can also provide a list of resources where you may find additional assistance.

Information provided in this application will be verified prior to approval for assistance.
Read and Understand the instructions. *

Yes, I have
I. Personal Data:

Tell us about yourself, your dependents and your financial situation.
Full Name *

First Name Middle Name Last Name
Birthdate: *

Month Day Year
Social Security Number : *
(e.g. 123456789)
Home Address : *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone No. : *

Area Code Phone Number
E-mail : *
Where the confirmation will be send to
Marital Status
Do you have a disability?

Yes No
Employment Status. *

0/300
Are you the sole provider in your home? *
How many occupants are in your home? *
Please provide the names and ages of any children or dependents.:
Are you currently receiving other assistance, i.e. government, other organizations? If so, how long? *

0/300
Have you received assistance in the past? From where and for how long? *

0/300
Please list the specific type of assistance you are seeking from KPIF. *

0/300
Please describe in detail why you need assistance from KPIF. *

0/300
Will you commit to volunteering at a later date to Pay It Forward? *

Yes No
VIII. Applicant's E-Signature
By signing (typing your legal name) in the space below, you are certifying that all information is correct and that you are the person completing this application. When you press the submit button, you will receive an email confirmation that your application was received. Please print for your records and retain as verification of your application.
E-Signature: *
Should be Empty:

I. Personal Data:

VIII. Applicant's E-Signature