General Application
Last
*
First Name
*
Maiden Name
Marital Status
*
Married
Single
Last 4 of SS#:
*
Date of Birth:
*
-
Month
-
Day
Year
Date Picker Icon
Street Address:
*
City:
*
ZIP code
*
What is your email address?
*
Phone number:
*
Ethnicity:
*
American Indian / Alaska Native
Asian
Black
Hispanic/Latino
Multiracial
Native Hawaiian and other Pacific Islander
White
Other
Highest Level of Education:
*
8th Grade or Less
Some High School
High School Diploma / GED
Some College
Associate's Degree
Bachelor's Degree
Graduate Degree
Other
Is there any other adults in the household?
Yes
No
How many adults are in the home?
Relationship of the other adults (spouse, roommate, family member):
What is the other adults' names?
Last 4 of the SS#
Date of Birth:
-
Month
-
Day
Year
Date Picker Icon
Number of Children in the Household:
*
No children
One
Two
Three
Four
Five
Six
Other
Please list the children's ages:
Employment History
Please share about your current and past employment.
Are you currently employed?
*
Yes
No
Looking for employment
Please name your current employer:
How long employed?
Previous employer?
If you are unemployed, how long have you been unemployed?
If you are unemployed, where have you applied for work?
If there is a second adult in the home, please share about their employment:
Assistance Request
If you were referred to Oaks of Central PA, please list the name of the individual or agency:
What service are you requesting?
*
Financial assistance on a water bill
Financial assistance on an electric bill
Financial assistance on rent / lease agreement
Financial assistance on prescriptions
Other
What is the amount needed:
*
How much can you put towards this bill?
*
For utility assistance, how long has the bill been in your name?
Again, for utility assistance, has the bill been in another name?
For rent assistance, please provide the landlord's name and contact phone number:
Are you living with someone due to being homeless?
*
Yes
No
Is someone living with you due to being homeless?
*
Yes
No
Explain why you need assistance or what crisis led you to seek assistance:
*
How will your situation change next month?
*
How many times have you moved in the last two months?
*
Zero
One
Two
Three
Four
Other
COVID-19 Related Questions
By answering these questions, Oaks of Central PA seeks to align you with resources to help you and your family through the COVID-19 pandemic.
Have you lost your job or had your work hours reduced because of COVID-19?
*
Yes
No
The question does not apply to my situation
If you are unemployed due to COVID-19, have you filed an unemployment claim?
*
Yes
No
I plan to file a claim, but I have not done it yet.
I am not unemployed due to COVID-19
Have you had problems getting COVID-related sick leave, or leave to care for a family member?
*
Yes
No
The question does not apply to my situation
Are you behind in your rent or mortgage? Or do you expect to get behind?
*
Yes
No
The question does not apply to my situation
Have you received a letter or notice telling you about eviction or foreclosure?
*
Yes
No
The question does not apply to my situation
Are you behind on payments for water, gas, electricity or landline phones? Or do you expect to get behind?
*
Yes
No
The question does not apply to my situation
For utility assistance, have you received a shut-off notice?
*
Yes
No
The question does not apply to my situation
Have your received your houshold's federal stimulus payment?
*
Yes
No
I am having problems with getting my federal stimulus.
Signature
Submit
Should be Empty: