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MCLTRG CLIENT INTAKE FORM

Please complete the form and a member of our team will contact you after final review.

Please select the type of assistance you are requesting *

Home Repair

Mortgage, Rent, Utilities

Client Information

First Name

Last Name

SSN (Last 4 Only)

Phone Number

Home Address

Home Address Line 2

City

State

Postal / Zip code

Email Address

General Information

Select an option *

Rent

Own

Select an option *

Mobile Home

Stick-Built Home

What year was your home built?

Total # of members in your household

Total # of adults in your household

Total # of children in your household

Use this space to describe the assistance you are requesting. (Only ONE request may be submitted every 24 months)

I attest the information entered is accurate and truthful.

Please enter your full name here as a digital signature

Thank you. Your form is under review.

CONTACT US

Contact us today!

Marion County Long Term Recovery Group is a tax-exempt fully accredited 501(c)(3) non-profit organization.

info@mcltrg.org

2523 E. Hwy 76

Marion, SC 29571

Phone: 843.275.6080

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