Assistance Request Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Please attach required doctors/social worker/case worker letter confirming intended assistance recipients medical diagnosis and need. * Click or drag a file to this area to upload. Your Name (Name of person filling out this form) *FirstLastAre you applying for yourself, or on behalf of someone else? *Applying for myselfApplying on behalf of someone elseIf applying for someone else, what is their relationship to you?Date of Birth of intended application recipient *Address of recipient/guardian *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail of recipient/guardian *EmailConfirm EmailPhone number of intended recipient/guardian *Date you hope to receive assistance by: *Amount of assistance request (estimated dollar amount) *Description of item/services to be purchased *How does this item/service fall in line with Granite State Generosity's mission to help those with life changing and life threatening diseases and disabilities, in NH?Acknowledgement (please check in agreement)I understand that completion of this request DOES NOT guarantee that assistance will be providedTo the best of the submitters knowledge, the proposed recipient is experiencing financial hardshipSubmit