Lagrange County Miracle Tree Christmas Application

Please complete all required fields before submitting.

BEFORE YOU BEGIN

Please enter information carefully and truthfully. If you have more than one child, complete each child section fully so Miracle Tree has the correct sizes, needs, and wish list details.

Applicant Information

Please complete the information below. If a question does not apply, enter N/A.

Name of Applicant*

First

Last

Address*

Enter your residential address.

Phone*

Include area code.

Alternate Phone

Optional. Enter N/A if not applicable.

Email Address*

We will use this to contact you about your application.

How many years has Miracle Tree helped you?*

Enter 0 if this is your first time receiving help.

Are You A Citizen Of The USA?*

Yes No

If you are not a U.S. citizen, you may need to provide additional documentation.

If no, please explain / documents

List All Adults In Household

Add each adult in your household. Include employer/self-employment and monthly income amounts. Enter 0 or N/A where applicable.

Children You Have Legal Custody Of

Add each child you have legal custody of. If there are additional people in the home that you cannot claim but that help your household total, note that in the additional information field in the child section.

No Income/Household Survival Questions

If there is no income in your home, please answer these questions. If this does not apply, enter N/A.

Who last worked?*

When did they last work?*

Last check received*

How is the family surviving with no income?*

Consent, Eligibility, and Certification

By signing this application, you are giving Lagrange County Miracle Tree consent to give your names and list of gift ideas for your children to other organizations who may "adopt" your family. They will keep your name confidential. Name WILL NOT be put on trees.

Lagrange County Miracle Tree will NOT be able to help your family if:

You do not live in Lagrange County, Steuben County or Sturgis, MI.
You do not provide the required documentation or give false information.
Over income.
Did not claim everyone in household or all income in household.
Illegally in United States.
Not enough help for applications received.

I affirm under penalty of perjury that my answers are complete and correct to the best of my knowledge. I am also aware that if I intentionally gave false information or double dip and signed up for multiple Christmas programs my application will be denied, and I may be permanently banned from receiving help.

Digital Signature*

Sign (type) to certify the information is complete and correct.

Date*

Authorization to Verify Application

I authorize the Lagrange County Miracle Tree to communicate with the following, in order to verify the accuracy of my application for assistance. This authorization applies to all sources listed below.

Verification authorization sources: Employers/Temp Agencies, Landlord, Division of Family Resources, WIC, Social Security Administration, CANI Trustees, Schools, Police Dept, Toys for Tots, Salvation Army, Other Agencies providing Christmas Assistance.

Name (for verification authorization)*

Date (verification authorization)*

Submit Christmas Application

You are ready to submit your application.

Supporting Documents*

Documents you MUST provide (Upload multiple files if needed):

State ID
Proof of residency
Birth Certificate for every child (that you have legal custody of)
Proof of income for the last 60 days (from all avenues)
Form showing if you receive state assistance (food stamp office)

Applications Closed