City Mission Ministries Outreach Program Qualifying Application
If you qualify, you can receive assistance through our food, clothing, household, and hygiene programs every 30 days. In case of an emergency within this period, you can discuss your situation with the assistant director. Please note that our program is not government-sponsored or city-run; it is funded by the generous donations of individuals who support low-income families, seniors, shut-ins, and the homeless. Your information remains confidential with City Mission Ministries and will not be shared outside the organization.
Basic Information
What city/county do you live in?
*
Please Select
San Bernardino County
Riverside County
Las Vegas, Nevada
By us asking which county/city you live in, helps us determine which mission branch will be assisting you based on proximity.
Name of Applicant
*
First Name
Last Name
Are you legally disabled?
*
Yes
No
Please explain your disability.
Are you currently homeless?
Yes.
No.
Do you own your house or rent?
I own the house I currently live in.
I rent the house I currently live in.
I am living with family/friends but I pay rent.
I am living with family/friends and do not pay rent.
How much is your rent/payments per month?
*
How many people live in your home?
Please list all those who live in YOUR house. Immediate Family only.
*
Address
*
Street Address 1
Street Address 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Apartment name
*
If you do not live in an apartment put "N/A."
Apartment and building number
*
If you do not live in an apartment put "N/A."
Do you live in a gated community
*
Please Select
Yes
No
What is the gate access number?
*
If you do not live in a gated community, put "N/A."
Do you live upstairs or downstairs?
*
Please Select
Upstairs
Downstairs
I live in a house
What is your primary phone number?
*
-
Area Code
Phone Number
What is your primary email address?
*
Confirmation Email
example@example.com
Vehicle Information
What form of transportation do you use?
*
If you own a vehicle, please enter the make and model.
*
If you do not own a vehicle, please enter "N/A."
Are you currently making payments? If so, how much?
If you do not make payments or do not have a car please enter "N/A."
Documents
PLEASE NOTE: If you submit your application without all document we need, your application will be immediately denied. Please include all necessary documents to avoid re-filling the whole form.
Please upload your proof of rent.
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Acceptable forms include: Rent payment receipt or mortgage payment receipt. Receipt needs to be within 1 month of filling out this form to be accepted.
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Please upload a proof of income.
*
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Acceptable forms include: Check stub, pension letter, SSI letter, unemployment verification or bank statement showing direct deposit.
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Picture ID identification must be provided for everyone 18 years or older living in your home.
*
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Acceptable forms include: Drivers License, Passport, or State ID. If you do not have any of the available options, you will need to fill out a application in person where City Mission staff will take a photo of you.
Cancel
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Please upload Identification for each individual or child under the age of 18 living in your home.
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Acceptable forms of identification include: Birth certificate, Medical Immunization card, or medical card.
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Submit
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