Financial Assistance Application

LINC NW Application for Basic Needs Assistance
Important Note:

Assistance requests are open this month from the first through the 12th.

Requests made on the 13th through the end of the month will be automatically forwarded to the following month and a determination will not be made until the 15th.

Determination of assistance is made by the 15th.

You will be contacted after that date as to the status of your request.

Other Notes:

We have a $500 limit per household every year.

We will not share any private information such as name, address, email, phone or other information with any other agency or organization.

Completion of this application is not a guarantee of financial or any other assistance.

Any Questions? Call or text our Resource Coordinator, Yana Ramos, at 425-409-9484. You can also email at yana@lincnw.org.

LINC NW
Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
May we text you at this number?

YesNo, please call or email
Email*
What are the best ways to contact you? (Select all that apply)*

TelephoneTextEmail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Birthdate*

MonthDayYear
Date
Race/Ethnicity

How many adults (18 years or older) live in your household?*
How many youth (under 18 years old) live in your household? *
Please list the first and last name of any one 18 or older living in your household.

What bill(s) do you need assistance with?*
How much is owed?*
To help us find the best way to support you, could you please share a bit about your current situation and what is making it difficult to pay this bill(s) right now? (We will not share this information.)

Download a Copy of Your Bill(s)

If we are able to help, we will need a photo or screenshot of your bill(s). Feel free to upload those images now for faster service or click on the 'Next' button to continue the application.
File Upload

Cancelof
File Upload

Cancelof

Were you referred to LINC NW by another agency or organization?*

NoYes (Please list their name)
Have you applied to any other organizations or agencies for financial assistance? If so, please list them here.
Anything else you would like us to know?

By submitting this form I agree that all of the statements inputted are true and accurate and understand that completing this form is not a guarantee of financial assistance.
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