Community Lifeline Financial Intake Application

Community Lifeline Financial Intake Form
Head of Household*

First NameLast Name
Date of Birth*

MonthDayYear
Upload photo of State ID*

Please make sure ID is legible.
Cancelof
Email*

Confirmation EmailPlease confirm your email address.
Phone Number*
Use the above format.
Service Area*
If your city is not listed, unfortunately you currently reside outside of our service area. If this is the case, please refer to www.findhelp.org to find an organization that may be able to assist you.
Current Housing*
Choose the option that best represents you.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please select your current employment status*
Choose the option that best represents you.
If you selected other, please explain your current employment status*
Are you a veteran?*

YesNo
I am requesting assistance for the following:*

Utility Assistance

Community Lifeline Agreements
All information submitted is true and accurate at the time of the application.*

I agree
If asking for Rental Assistance, I authorize my landlord to release information on my account to Community Lifeline Center Staff*

I agree
If asking for Utility Assistance, I authorize Community Lifeline Center to access my utility account and authorize my utility provider to release information to Community Lifeline Center Staff.*

I agree
Signature*

Clear

Thank you for completing the application. Unfortunately, you do not qualify for our Financial Assistance Program. Please submit the application on the next page so a Case Manager may reach out to you via email to provide more information and additional resources.
Please enter your email to receive additional information about your application.*
example@example.com

Submit Application

You have completed the application. Please hit the submit button below.
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Community Lifeline Financial Intake Form