Emergency Assistance Application

Emergency Assistance Application

We require 10 days for processing a completed application. If there are any missing required documents, the application will be halted until all information is received. This will delay the emergency assistance decision. If you have not heard from our office within the 10 days, give us a call at 616-236-1027.
Name *

First Name Middle Initial Last Name
Address *

Street Address

Street Address Line 2

City State

Zip Code
County *
Phone Number *
Please enter a valid phone number.
Email
example@example.com
Preferred Choice of Contact (Contact will be during our business hours of 8:00 - 4:30): *

Phone Text Email
Are you a veteran? *

Yes No
How did you hear about us?
What is your emergency need? (List all that apply) *
Please include percentage of propane left.
Please Note: Payment for deliverable fuel will not be made if, upon delivery, it is confirmed you have more than 25% remaining in your tank. You will then be responsible for the cost of delivery.

Household Members

Include everyone living in the household, including self. Please start with yourself.
Household Members *

Income Verification

Include all household income.
Acceptable Proof Of Income

Earned Income: Be sure all pay stubs are clear. Employee's name, employer/source name, dates of pay period, and gross amount of pay (including tips if applicable) must all be legible.
- Pay Stubs: Provide number of pay stubs dependant on how often recieved.
  - Weekly - 5 pay stubs
  - Bi-Weekly - 3 pay stubs
  - Monthly - 2 pay stubs
- Self-employed individuals must provide the previous year's state income tax forms, including profit and loss statement as proof of income.
Unearned Income: (No Bank Statments)
- SSI, Social Security, RSDI, SSDI : Must provide 2022 benefit award letter.
- Quarterly SSI Supplemental verification
- Pension Letter/statement.
- Veteran Benefits Awards Letter
- Child Support: Must provide MICase print off showing past 90 days of income.
- Unemployment: Must provide current UIA print off or UIA Award Letter.
- Cash Assistance: Provide DHHS Case Action Letter showing past 90 days.
- Adoption Subsidy/Direct Care through the State: Provide copy of pay stubs for past 90 days.
- Worker's Compensation: Provide 90 days of pay stubs.
- Alimony or Spousal Support: Provide Divorce agreement or MICASE statement.
- Adoption Subsidy/Direct Care letters.
- Interest, Annuities, or Dividends.
- Rental Income : Provide statements and reciept.
- Other Income: Cash from employment, cash from friends or family, ect. (A written statement including employer/family member name, address, and phone number must be provided)
Does household have income? (If yes, add all income below. If no, skip and move on to next section.) *

Yes No
Household Income
Has there been any, or do you expect any changes in your household's income in the next 30 days? (Please provide verification from employer of this change) *
If previous answer was yes explain.
Upload Income Documents

Cancel of

Required Information for Requesting Service(s)

Please upload all paperwork that applies to your situation.
Include With Every Application:
- Valid Driver’s License or State issued ID or School ID or US Military Card or US Passport
- Social Security Card for applicant and/or name on bill
- DHHS decision letter
- Signature Statement
- COVID Statement
Include If Needing Help With Utility/Propane Assistance:
- Utility shut-off notice
Include If Needing Help With Rental Assistance, Evictions, Deposit:
- Lease
- Eviction Judgment
- Proof of Voucher
- Proof of apartment approval
Include If Needing Help With Repair Assistance
- Estimates from 3 different companies
If there are any missing required documents, the application will be halted until all information is received. This will delay the emergency assistance decision.
File Upload *

Cancel of

EightCAP, Inc. Agency Consent/Release of Information
I, First Name Last Name ,give EightCAP, Inc. consent to release, obtain and share all pertinent information and non-confidential social, medical, and other information about myself and information I have provided about additional family members that will allow me and my family to benefit from services offered. In granting such permission, I understand that such information will remain confidential and that such information will only be used for my benefit or to benefit other members of my family. Only authorized personnel will share client information needed for service delivery, to track demographic trends, service patterns and the client outcomes achieved. I further understand that information regarding myself and additional family members will be entered into the data management system(s) utilitzed by EightCAP, Inc. I release EightCAP, Inc. and its staff from any legal liability for disclosing or acquiring information that I have permitted by signing this form.

By signing below, I understand that unless I make a formal request to EightCAP, Inc. that I no longer want to participate in the services offered; this release will remain in effect for three (3) years from today. The statements made by me are true, correct, and complete to the best of my knowledge.

I understand that I have the right to revoke this authorization at any time by submitting a written cancellation to EightCAP, Inc. and my services will be terminated.
Please select the agencies we have the right to release information to:

Department of Health and Human Services (DHHS) Community Management Associates (CMA) Community Mental Health (CMH) Property Management Community Action Agencies Other
Signature

Clear

COVID Statement & Signature Statement
I, First Name Last Name , consent for my electric signature on my EightCAP documents.
Explanation of how you have been financially affected by COVID: *

CAA, its agent, partners and funding sources do not discriminate on the basis of race, color, sex, religion, nationality, disability, or marital status. If you, the applicant, feel you were treated unfairly or denied service(s), please notify the agency in your county of residence to appeal and request a fair hearing. Your application will be properly reviewed to determine eligibility based on the required documentation provided.

UNDER PENALITES OF PERJURY, I SWEAR OR AFFIRM THAT THIS APPLICATION HAS BEEN EXAMINED BY, OR READ TO ME. IF I AM A THIRD PARTY APPLYING ON BEHALF OF ANOTHER PERSON, I SWEAR THIS APPLICATION HAS BEEN EXAMINED BY, OR READ TO THE APPLICANT AND TO THE BEST OF MY KNOWLEDGE THE FACTS ARE TRUE AND COMPLETE.
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

Emergency Assistance Application

Household Members

Income Verification

Required Information for Requesting Service(s)

EightCAP, Inc. Agency Consent/Release of Information

COVID Statement & Signature Statement