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2. Community Development Assistance Program Inquiry.

   For Citizens of Jacksonville Arkansas only

4. First Name*
5. Last Name*
7. Address1*
9. City*
10. State*
11. Zip*
13. Email Address*
15. Please select what type of COVID Financial Assistance you are requesting.

    1. Rental Assistance
    2. Utility Assistance
    3. Both
    4. None
17. Comments
19. Please select what type of Rehabilitation Assistance Grant.

    1. Rehabilitation Program
    2. Handicap Accessibility
    3. None
21. Comments
23. Are you interested in the Home Buyers Assistance Grant

    1. Yes
    2. No

25. Thank you for your request(s).  A reply will be coming shortly.

Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit Submit and Print

* indicates a required field