Intake Form

Assistance Information
Auto Repair PaymentDentist PaymentDoctor Visit PaymentPrescription PaymentRent PaymentHome Repair PaymentVision PaymentUtility PaymentFood Assistance
Name of Company or person to issue Check*
Email of Company or person to issue payment
example@example.com
Phone Number of Company or as listed on Bill or Lease*

Area CodePhone Number
Account number on Bill if applicable
Address to Mail Check*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Payment was Due

MonthDayYear
Date
Amount To Pay*
Amount you are able to contribute*
Total Amount needed for Assistance
Upload Bill or Estimate

Browse Files

Cancelof
You have selected Rent Payment as your need. To complete your intake form please direct your landlord to go to https://www.wyohelp.com/vendor-portal.html and complete their portion of the payment information. We must have your landlord's tax information on file to complete the payment.

Signature Page
YesNo
YesNo
Your application will not be processed until we have received all required documents. Please make sure you have submitted all required income documents or statements.
Head of Household Signature*

Clear
Anything you want us to know?
Should be Empty:

Family Information