Assistance Request Application
Please fill out all portions of the form. Once your request has been submitted and reviewed, you will receive a call at the number provided.
Contact Information
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
E-mail
example@example.com
Identity Verification
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We will need a copy of a driver's license or state issued ID in order to provide any type of assistance. You can upload that via computer or mobile device. If you are unable to use either of these options, we can collect at a later date.
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How many additional household members do you need to add?
*
Please Select
None
1
2
3
4
5
Tell us about your household members below:
I.E. Spouse/partner, children, extended family member, etc.
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Assistance
If you have not visited Needline before filling out this application, we require that you start there. They can be reached at (270) 753-6333.
Are you a resident of Calloway County, KY?
*
Yes
No
How long have you lived in Calloway County?
*
Have you received assistance from University Church of Christ before?
*
Yes
No
If yes, please explain below.
Have you visited Needline about this assistance request?
*
Yes
No
If you have visited Needline, let us know about your visit. If declined, please explain why your request was declined by Needline.
Date you visited; Caseworker's name; Were they able to help? If no, why?
What type of assistance are you applying for?+
*
Rental
Electric
Utility
Gas card
Hotel Stay
Please fill out the section that you are applying for assistance.
Use the drop down arrows to expand the section.
Rental Assistance Request
If you are applying for rental assistance, how much is your monthly rent?
How much are your requesting towards your rent?
Please in explain in detail, i.e. full month payment, past due amount, etc.
Landlord Name & Number
Electric Assistance
What electric company do you use?
Murray Electric
West Kentucky Rural Electric
Which payment option do you use?
Monthly Bill
Prepay
What is your account number?
Please include ALL digits and dashes.
Have you been disconnected?
Yes
No
Within a day or two of disconnection
How much are you requesting in electric assistance?
Please provide image of your bill below:
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Utility Assistance
What is your account number?
Please include ALL digits and dashes.
Have you been disconnected?
Yes
No
Within a day or two of disconnection
Please provide image of your bill below:
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Choose a file
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Gas Card
Have you received a gas card from University Church in the last 6 months?
Yes
No
Unsure
Why do you need a gas card?
Hotel Stay
Have you visited HOPE Calloway for housing assistance?
If yes, please explain help received.
Are you currently staying in a hotel?
Yes
No
If yes, where are you staying?
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Thank you for taking the time to fill out our assistance request application. If there are any other details you think we should know, please let us know below.
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