Lagrange County Miracle Tree Emergency Application

Please complete all required fields and upload necessary documentation.

Applicant Information

Name of Applicant*

First

Last

Address*

Phone*

Email Address*

What type of assistance are you seeking?*

Amount Requested ($)*

Please explain your current emergency / hardship in detail.*

Upload Required Documents*

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

State ID
Proof of the Emergency (Eviction notice, Utility shut-off notice, Medical bill, etc.)
Proof of Income for the last 30 days

Digital Signature*

By typing my name, I certify the information provided is correct.