Are You Eligible To Apply

Name*

First Last

Email*

Enter Email Confirm Email

Address

Street Address Address Line 2 City State ZIP Code

Do you live or work in a community where we operate a Jack's Family Restaurant?*

Jack's Family Restaurant is a regional chain that operates primarily in Alabama (north of I-10). We also have a few restaurants in Mississippi, Tennessee, and Georgia. To find your closest Jack's visit Find a Jack's

Yes
No

We are sorry you are going through a difficult time. However, we only offer assistance to those who live or work in a community where we operate a Jack's Family Restaurant. Therefore, you are not eligible to apply. To find other community resources, please contact your local 2-1-1 service or visit 211.org

Are you seeking a contribution toward your loved one's funeral/burial?*

Yes
No

Is your current need the direct result of one of these hardships:*

accident
crime
death
fire
Currently homeless or in danger of eviction/foreclosure
illness
natural disaster/ storm

Yes
No

Prior to this hardship, were you able to afford all of your essential living expenses?*

Essential living expenses include housing, utilities, groceries, and medical care.

Yes
No

Is your need an expense for which we offer assistance?*

funeral/burial
rent/mortgage
utilities (electric, water, natural gas)
groceries/toiletries
life-saving medical (prescriptions, treatments, procedures)
temporary, emergency shelter

Yes
No

Are you currently (or will you be within the next 30 days) without access to any of the following:*

housing/ shelter
running water
electricity
heat
2 or more nutritious meals per day
basic clothing and personal care items
essential medical treatment/procedure

Yes
No

Screening Evaluation