Application for Assistance

  • Application for Assistance

    Updated February 2026

  • Please fill out this application according to your needs. You must complete the budget portion to the best of your ability and knowledge. We cannot process any applications without the budget portion completed and two months of bank statements. After submitting the form, our team will review your application and contact you to set up a meeting. Please note, this process can take up to two weeks.

    Cornerstone is only able to help individuals and families living in Perry County, Pennsylvania once per 365 days. If you apply from outside of Perry County, PA you will not receive a reply to your request. If you do not complete the budget portion and submit two months of bank statements you will not receive a reply to your request.

    If you need any assistance with the application or have any questions, please call the office at 717-834-4641.

  • Are you a Perry County, Pennsylvania resident?*
  • Format: (000) 000-0000.
  • I prefer to be contacted via:*
  • Date of Birth*
     - -
  • Marital Status*
  • Are there additional members of your household?*
  • Rows
  • Are you or any other members of your household currently involved with any other agencies (check all that apply):*
  • Are you receiving any aid or funding from a government program/agency?*

  • Benevolence Team

    Our team consists of volunteers who schedule appointments around their jobs and family schedules.
  • What type of assistance are you seeking?*
  • Have you or anyone in your household been assisted by Cornerstone in the past?*
  • Have you contacted anyone else regarding your current need? (Please select all that apply)*
  • Have you contacted anyone else for assistance in the past 6 months (not related to what you are seeking today)?*
  • Do you currently rent or own your home?*
  • Do you have access to a car?*
  • Do you have a monthly car payment?*
  • Do you have a monthly budget?*
  • Are you legally able to work in the United States?*
  • Are you currently employed?*
  • Do you attend a local church? (Please note, this question has no influence on your eligibility to receive assistance).

  • Disclaimer and Signature

    I hereby authorize the release of information to Cornerstone Christian Church to receive assistance I am requesting. I further certify the information I have provided is true and correct and that all income has been reported. I understand that Cornerstone may verify the information on the application and any deliberate misrepresentation of information will be subject to denial of assistance and services. I authorize Cornerstone to discuss my case with other agencies, businesses, churches, attorneys, individuals or others deemed necessary to verify the accuracy of information and/or identify additional sources of assistance. I understand that all information will remain as confidential as possible within these entities. I understand that Cornerstone may search public records to verify information. I have read, understand and agree to the policies above regarding the Release of Information.

  • Monthly Budget Form

    Please fill out the following budget assessment to the best of your abilities. By providing this information, it gives us more information on the best course of assistance to help meet your need. You will also need to provide 2 months worth of bank statements. Please make sure your account number is not visible when you download your bank statements.
  • Rows
  • Rows
  • Have you applied for LiHeap?*
  • Have you been approved for assistance through LiHeap?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Should be Empty: