Financial Assistance Application

We are now able to offer our Financial Assistance Application online. Please gather the following information before beginning the application: names, social security numbers, and income information for all in your household; monthly bill amounts and account numbers; income sources including wages, social security payments, etc.

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Your Information

Name *

First

Last

Maiden Name (if applicable)

Contact Phone Number *

Email *

Confirm Email

Social Security Number *

ID Number (if you don't have a Social Security Number)

Date of Birth *

Street Address *

Address Line 1

Address Line 2

City

State

Zip Code

How long have you lived at this address? *

How many bedrooms are in your house/apartment? *

Prior Address *

Address Line 1

Address Line 2

City

State

Zip Code

Name of Employer: *

How long have you been employed there? *

Where did you work before that? *

How long did you work there?

Do you attend church? *

What church do you attend? *

Spouse Information

Are you married? *

What is your spouse's name? *

What is your spouse's Social Security Number? *

If your spouse doesn't have a SS#, what is his/her ID Number?

What is your spouse's date of birth? *

Where does he or she work? *

How long has he or she worked there? *

What is your spouse's income? *

Others in Household

1. Does anyone else (not listed above) live with you? *

Person #1 Name *

First

Last

Person #1: What is this person's relationship to you? *

Person #1: Date of Birth *

Person #1: Social Security Number *

Does Person #1 have any income? *

Person #1: Income Source *

Person #1: Income amount *

2. Does anyone else (not listed above) live with you?

Person #2 Name *

First

Last

Person #2: What is this person's relationship to you? *

Person #2: Date of Birth *

Person #2: Social Security Number *

Does Person #2 have any income? *

Person #2: Income Source *

Person #2: Income Amount *

3. Does anyone else (not listed above) live with you?

Person #3 Name *

First

Last

Person #3: What is this person's relationship to you? *

Person #3: Date of Birth *

Person #3: Social Security Number *

Does Person #3 have any income? *

Person #3: Income Amount *

Person #3: Income Source *

4. Does anyone else (not listed above) live with you?

Person #4 Name *

First

Last

Person #4: What is this person's relationship to you? *

Person #4: Date of Birth *

Person #4: Social Security Number *

Does Person #4 have any income? *

Person #4: Income Amount *

Person #4: Income Source *

5. Does anyone else (not listed above) live with you?

Person #5 Name *

First

Last

Person #5: What is this person's relationship to you? *

Person #5: Date of Birth *

Person #5: Social Security Number *

Does Person #5 have any income? *

Person #5: Income Amount *

Person #5: Income Source *

6. Does anyone else (not listed above) live with you?

Person #6 Name *

First

Last

Person #6: What is this person's relationship to you? *

Person #6: Date of Birth *

Person #6: Social Security Number *

Does Person #6 have any income? *

Person #6: Income Amount *

Person #6: Income Source *

Type of Assistance Needed

What type of assistance do you need? *

Rent
Rent Deposit
Utilities
Utilities Deposit
Medicine
Other

Is your name on the lease? *

Is the utility bill in your name? *

Please list the name, dosage, and frequency of the medicine: *

If other, what type of assistance do you need? *

What amount of assistance do you need? *

What amount can you provide toward this bill? *

If you have a copy of the bill or other documentation of the expense, please take a clear photo and upload it here.

Click or drag a file to this area to upload.

Sources of Income/Assistance

Are you employed now? *

How often are you paid? *

Monthly
Every Two Weeks
Every Week

How much are you paid per pay period? *

Do you receive Supplemental Security Income (SSI)? *