Service Request

Exceptional Hearts is expanding its eligibility criteria to support single parents and individuals who have lost SNAP benefits, and government employees who have lost pay.

To qualify, individuals or single parents must provide documentation confirming the cancellation of their SNAP benefits. *After filling out information, answer questions marked with a "SNAP."

If you work for the government, you will need to show proof that you are a current employee currently without pay.

If you are over 60 and/or facing homelessness, you do not need proof of cancellation.

Last name*

Phone*

Address*

Members in Household*

Anyone in the home with a physical, intellectual, or developmental disability? (autism, wheelchair bound...)

Ages of all household members.

What are you in need of?

Food

Toiletries (For unhoused and elderly)

Are you over the age of 60? (Proof of age will be required)*

Yes

Are you experiencing homelessness? This can include not having a place to sleep, living in a shelter, car or on the streets, couch surfing, and/or living in a motel.

Yes

Douglas County, GA Resident Acknowledgement

By checking this box, I acknowledge that I am a resident of Douglas County, GA.

(SNAP) Date of cancellation

(SNAP) Do you have proof of cancellation?

YES

I am a government employee. (You will need to proof of employment status.)

YES