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Do you regularly attend Crossfire? Yes No

If yes, for how long?

What church (other than Crossfire) do you regularly attend?

How did you hear about Crossfire?

What kind of assistance are you asking for and why from Crossfire?

Who should the check be written to? (I.E. utilities, property management co., etc.; it cannot be written directly to you.) Please include mailing address for the company and acount number (if applicable.)