Relief Fund Application

Faith Fund Application
Complete this application, client release form and Household information before submitting. You will be contacted by a Faith Fund representative by telephone to schedule an interview. All information will be kept confidential. Be sure to scroll all the way to the end and hit the SUBMIT button. You will received an email notification that it was submitted. All applicants must reside in Wells County to be considered for assistance.
Full Name*

First Name Last Name
Home Address *

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
County of residence - you MUST be a resident of Wells County, Indiana to receive assistance. NO EXCEPTIONS*
How long at this address?*
Date. of birth*

MonthDay Year
Date
Phone Number*

Area Code Phone Number
Previous Address*

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Email*
example@example.com
Assistance requested*
Please describe IN DETAIL the circumstances that require you to seek assistance, not just that you need help - but what has caused you to need help.*
Do you receive child support and how much?*
Do you pay child support and how much?*
Landlord's Name*

First Name Last Name
Landlord's Phone Number*

Area Code Phone Number
Monthly Rent*
Are you behind in rent? How much?*
Near eviction?*
Number of adults in household full time?*
Number and ages of children (under 18) in household full time?*

HOUSEHOLD INFORMATION

List names of EVERYONE (children and adults) living in your household AND the amount of income for each. If not employed, please state why (unless they are under 18). List assistance currently being received for each as well.
Name of Person completing application*

First Name Last Name
Date of birth*

MonthDay Year
Date
Monthly Income*
Employer*
How long employed there?*
Food Stamps (SNAP) Amount
SSI $
TANF $
SSD $
WIC $
Unemployment $
Medicare/Medicaid $
Other Income
Date of High School Diploma

MonthDay Year
Date
Date of GED

MonthDay Year
Date
School name and location*
Veteran?*

Name of additional people residing with you

First Name Last Name
Relationship to Applicant
Date of Birth

MonthDay Year
Date
Employer
Monthly Income $
Food Stamps (SNAP) $
SSI $
TANF $
SSD $
WIC $
Unemployment $
Medicare/Medicaid $
Other Income $
Date of GED

MonthDay Year
Date
Date of High School Diploma

MonthDay Year
Date
School Name and location
Veteran?

Name of additional people who reside with you

First Name Last Name
Relationship to Applicant
Date of Birth

MonthDay Year
Date
Employer
Monthly Income $
Food Stamps (SNAP) $
SSI $
TANF $
SSD $
WIC $
Unemployment $
Medicare/Medicaid $
Other Income $
Date of GED

MonthDay Year
Date
Date of High School Diploma

MonthDay Year
Date
School Name and location
Veteran?

Name of additional people who reside with you

First Name Last Name
Relationship to Applicant
Date of Birth

MonthDay Year
Date
Employer
Monthly Income $
Food Stamps (SNAP) $
SSI $
TANF $
SSD $
WIC $
Unemployment $
Medicare/Medicaid $
Other Income $
Date of High School Diploma

MonthDay Year
Date
Date of GED

MonthDay Year
Date
School Name and location
Veteran?

Name of additional people who reside with you

First Name Last Name
Relationship to Applicant
Date of Birth

MonthDay Year
Date
Employer
Monthly Income $
Food Stamps (SNAP) $
SSI $
TANF $
SSD $
WIC $
Unemployment $
Medicare/Medicaid $
Other Income $
Date of High School Diploma

MonthDay Year
Date
Date of GED

MonthDay Year
Date
School Name and location
Veteran?
Do you need more pages to list more in your household? We will email them to you.

CLIENT RELEASE FORM
Address*

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Phone Number*

Area Code Phone Number
Date of Birth*

MonthDay Year
Date
Social Security Number - you will be asked to provide this during your phone interview -
I give consent for United Way/Faith Fund to obtain and/or release written and/or verbal confidential information regarding my status/involvements to the agencies/persons listed below. The type of information obtained and/or released will be for the purpose of eligibility determination, implementing, monitoring a plan or service. Types of information obtained and/or released may include, but not be limited to, income information, status with a particular agency, service rendered, problem situations, general progress, etc. You will be asked for your social security number during your phone interview.

Indiana Family & Social Service Admin.

Department of Child Services

Township Trustee

Landlords

Pastors

Unemployment office

Community and Family Services

Local Food Banks

Utility companies

Employment agencies

Law enforcement agencies

Employers

Mortgage companies

Any agency, institution, company or person that may have given assistance or in which I have had resources available to me.

I further agree that I will hold harmless any person, agency, copany or institution who gives information to the United Way/Faith Fund about me.

This consent form is valid for three years from date signed and may be revoked by me, in writing, at any time. All information will be kept confidential.
By completing my printed name and submitting this application, it will be a binding signature giving consent.*

First Name Last Name
Should be Empty:

Faith Fund Application

CLIENT RELEASE FORM