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Date
First name
Last name
Address
City
State
Zip
Telephone
Email
County
Pitt
Martin
How many in household
Do you Receiver Medicaid
No
Yes
If Yes .Who is your Provider
United Health Care
Aetna
BlueCross BlueSheild
Other Provider
Do you have a Budget ?
Yes
No
Do you have a Job ?
Yes
No
Do you have a Pet ?
Yes
No
If yes
Cat
Dog
Both
Are You homeless ?
Yes
No
Are you a Veteran ?
Yes
No
Are you a Senior ?
Yes
No
Are You Release for Prison ?
Yes
No
Are you disabled ?
Yes
No
Do yo receive SNAP ?
Yes
NO
Do you need Legal Assistance ?
Yes
No
Do you need educational referral assistance ?
Yes
No
Do you have Children
Yes
No
If yes how many
What do you need help with.
Food Box
Pet Food
Rent bill
Light bill
House cleaning Classes
Budget Class
Health Class
Veteran Services
Senior Services
Legal Advise
Job Training
Children Services
I Call 252 227-0698 for need for
Food
Light bill
Rent
Refer By Church
Church Name
Pastor Name
Rerfer by
Rev.Dr Rodney Coles Sr
Community Feeding Our Children
Community Faith Outreach
Cornerstone Family Worship Center
Crossing The Bridge
Four Day Movement INC
Saint Paul's Episcopal Church Greenville
Joy Soup Kitchen
St John Church Stokes
First Presbyterian Church Greenville
St Luke Church Greenville
Hope of Glory
Bethel Resource Center
Infinity Outreach
Food bank
Dept Of Social Service
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Community Unity Network
Greenville, North Carolina 27834
252 296-1237
cunetwork2015@gmail.com
https://bmr2016.com/
