Financial Assistance Application

Lutheran Community Services

Assistance Application
Eligibility Requirements

Please review the requirements to qualify for assistance below.

You must be a legal Delaware resident
You can NOT have received financial assistance from LCS in the past 24 months
You must be able to provide required documentation (e.g. photo ID, social security card, proof of income, proof of need - utility bill or landlord letter, and other documents as requested)
Your Total Monthly Income can not exceed the following:

Household Size	1	2	3	4	5	6
Maximum Income	$3,075	$3,516	$3,954	$4,391	$4,745	$5,095

Are you a renter?*

YesNo
Are you a DE resident?*

YesNo

FOR EACH MEMBER OF YOUR HOUSEHOLD: Please attach a copy of your Drivers Licence or State issued photo ID

Cancelof
Please attach proof of Income, most recent pay stub preferred

Cancelof

Lutheran Community Services

Assistance Application
Monthly Expenses

Enter each item on a monthly basis. If you do not have an expense listed, enter "0" in the amount column.

Lutheran Community Services

Assistance Application
Monthly Income

Enter each item on a monthly basis. If you do not have an income listed, enter "0" in the amount column.

Lutheran Community Services

Assistance Application
Monthly Budget Totals
Total Monthly Expenses
Total Monthly Income
Net Monthly Income
If this information is correct, click Next

Lutheran Community Services

Assistance Application
Emergency Situation Financials
Total Amount Needed*
Example: Total Rent Payment, Combine Utility Bill and Deposit, etc.
Client Will Cover
How much are you able to afford out of pocket?
Other Sources
Example: Aid From Relatives, Other Organizations, etc.
Requested of LCS
How much support are you asking from LCS?

Lutheran Community Services

Assistance Application
Household Member Information
Total Number of Household Members*

Lutheran Community Services

Assistance Application
Signature*

Clear
Date
Should be Empty: