Assistance Application Form

This is a general assistance program.

Limited funds are available. Applications take several weeks to process.

Please return the application and necessary paperwork as soon as possible.

Failure to return the completed application and all supporting documentation may result in denial of your application. Please upload copies of the documentation. If any of the supporting documents are unavailable, use the comment section to state why they are not included.

Todays Date * +

The following supporting documents MUST be submitted in order to process your application:

If you receive financial assistance from any of the following programs; Include the ones you and your family receive in the comment section. Also, please provide documentation for proof along with your case number. If denied, please provide proof of denial.

SNAP (Supplemental Nutrition Assistance Program)
Childcare Financial Assistance
State Health Insurance Programs or Forward Health
TANF (Temporary Assistance for Needy Families)
WIC (Women, Infants, and Children)
Low Income Energy Assistance Programs

If you are on Social Security Disability or over the age of 65, please include your Medicaid deductible eligibility date and dollar amount. If you have been denied by the Medicaid deductible program, please provide a copy of denial.
Copy of most recent Federal Income Tax Return and W-2 Forms, Schedule C tax forms if you and/or your spouse are self employed, and any additional tax schedules filed.
Proof of income. If married, include your spouse's information, please submit one month of current pay stubs.
Past 3 months of bank statements on every bank for which your and/or your spouse's name appears; including direct deposit debit cards. A summary will not be accepted.
If you and your spouse are unemployed and receiving unemployment compensation, supply a verification of unemployment benefits.
If you are leasing, please provide a copy of your lease.

Please provide a reference to a well-known community member or Imam that knows you *

Contact full name *

Phone Number *

How many dependents live with you? *

How old are dependents? *

Are you a Refugee? *

Yes

What Agency did you come through?

Case worker name and phone number

Employment Status

Employment Status: *

Employed

Unemployed

Place of Employment: *

Work Phone: *

Total Monthly Income: *

Any Assistance Being Received: *

Food stamps/WIC

Medicaid/Title 19

Please list any other assistance that you receive: *

Please upload income documents and ID

Lease Information

Land Lord Name (Put N/A if you do not need rent assistance): *

Land Lord Phone Number (Put 0 if you do NOT need rent assistance) *

Please provide your street/Mailing Address (Street Address, City, State, Zipcode) *

Please upload the following - 1. Lease Agreement 2. Late Rent Notice 3. Utility Bills (if needed) *

Reason for Assistance

Please explain why you need assistance: *

Total Amount of Assistance Needed: *

Signature of Applicant: *

clear