Project ElderCool

Application Status
Today's Date

MonthDayYear
Date Begin

MonthDayYear
Enter as ONE day prior to Start Date
Date End

MonthDayYear
- Project ElderCool
  Currently accepting applications!
  
  Click NEXT to continue.
- Project ElderCool
  Season has Ended!
  
  Please check back next summer.

Application CLOSED
Project ElderCool
NOT accepting applications!

Please check back next season.

Air Conditioning Relief

for Elderly and Individuals with a heart condition or respiratory disability
Project ElderCool
can ONLY provide A/C Assistance
ONCE per Household in 3 years

Disposition
Are you 63 years old or over?
- Affliction requiring air conditioning:
  
  Other
- You MUST provide a note from doctor.

Accommodations
Type of Residence:
Residing Status:
- IF Approved, will landlord permit installation of A/C unit?

Release of Information and Privacy Policy
The information I provide is true and correct. I understand that my information is electronically tracked through MAACLink in order to assess my household needs and provide better services such as housing, utility assistance, food, and other services. My information may be shared among the agencies from which I have requested emergency assistance or case management. If I am applying for utility or rent/lease assistance, my information will be shared with my utility or landlord/leasing company by phone, email, or in written form in order to process the application and secure payment to the correct account. Donors are often shared stories without giving identifying information. These stories are impactful to further our ability to provide funding.
Signature

Disqualified - NO Release Agreement
Bishop Sullivan Center is only able to help when
you agree to the Release of Information and Privacy Policy.

You can contact United Way of Greater Kansas City
who provides information of other agencies
that may be able to offer assistance to you
by calling 2-1-1
or visiting https://www.unitedwaygkc.org/get-help

Utility Designation
What is the Electric Utility Provider company name?
What is your Electric Utility Account Number?

(6-20 characters)0/20

Household Information
Provide the names and dates of birth for
all adults and all children in this household.
Include any income sources and amounts
each person contributed to the entire household
in the last 30 days.

Note: Enter the gross monthly income
(the actual amount received before taxes)
for the last 30 days.
Please do not estimate but
enter the actual amounts and
include all sources that apply.

Primary Household Contact Information
Primary Contact Name:

First NameLast Name
Primary Contact Date of Birth:

MonthDayYear
Pick date from calendar!
Primary Contact Street Address: (Current)

Street Address

Apartment/Suite/Office

CityState

Zip Code
Provide a telephone number and/or e-mail address at which you can be contacted:
- Primary Contact Telephone Number:
  Format: 000-000-0000.
- Primary Contact Email Address:
  example@example.com

Primary Household Income
The following three items are for the application but are not considered as sources of income. Include any amounts received from these three sources for {HH1Name}:
#1 Food Stamps
#1 Utility Check
#1 Section 8 or Income-base Housing
Please list GROSS income amounts of all types received in the last 30 days by {HH1Name}:
#1 Employment:
Enter 0 if none
#1 Social Security:
Enter 0 if none
#1 Unemployment:
Enter 0 if none
#1 Child Support:
Enter 0 if none
#1 T. A. N. F.
Enter 0 if none
#1 OTHER:
Enter 0 if none
- If #1 OTHER, please explain:
- Primary Household Total Income:

NO Primary Household Income
NO sources of income have been indicated in the last 30 days. Please explain how expenses have been met in the last 30 days.

(25-100 words)0/999

Additional Household Members
Is there another person in the household after {HH1Name}?

Household Member #2 Information
Name of Household Member #2:

First NameLast Name
Date of Birth for Household Member #2:

MonthDayYear
Pick date from calendar!
The following three items are for the application but are not considered as sources of income. Include any amounts received from these three sources for {HH2Name}:
#2 Food Stamps
#2 Utility Check
#2 Section 8 or Income-base Housing
Please list GROSS income amounts of all types received in the last 30 days by Household Member #2:
#2 Employment:
Enter 0 if none
#2 Social Security:
Enter 0 if none
#2 Unemployment:
Enter 0 if none
#2 Child Support:
Enter 0 if none
#2 T. A. N. F.
Enter 0 if none
#2 OTHER:
Enter 0 if none
- If #2 OTHER, please explain:
- Household Member #2 Total Income:
- Is there another person in this household after Member #2:

Household Member #3 Information
Name of Household Member #3:

First NameLast Name
Date of Birth for Household Member #3:

MonthDayYear
Pick date from calendar!
The following three items are for the application but are not considered as sources of income. Include any amounts received from these three sources for {HH3Name}:
#3 Food Stamps
#3 Utility Check
#3 Section 8 or Income-base Housing
Please list GROSS income amounts of all types received in the last 30 days by Household Member #3:
#3 Employment:
Enter 0 if none
#3 Social Security:
Enter 0 if none
#3 Unemployment:
Enter 0 if none
#3 Child Support:
Enter 0 if none
#3 T. A. N. F.
Enter 0 if none
#3 OTHER:
Enter 0 if none
- If #3 OTHER, please explain:
- Household Member #3 Total Income:
- Is there another person in this household after Member #3:

Household Member #4 Information
Name of Household Member #4:

First NameLast Name
Date of Birth for Household Member #4:

MonthDayYear
Pick date from calendar!
The following three items are for the application but are not considered as sources of income. Include any amounts received from these three sources for {HH4Name}:
#4 Food Stamps
#4 Utility Check
#4 Section 8 or Income-base Housing
Please list GROSS income amounts of all types received in the last 30 days by Household Member #4:
#4 Employment:
Enter 0 if none
#4 Social Security:
Enter 0 if none
#4 Unemployment:
Enter 0 if none
#4 Child Support:
Enter 0 if none
#4 T. A. N. F.
Enter 0 if none
#4 OTHER:
Enter 0 if none
- If #4 OTHER, please explain:
- Household Member #4 Total Income:
- Is there another person in this household after Member #4:

Household Member #5 Information
Name of Household Member #5:

First NameLast Name
Date of Birth for Household Member #5:

MonthDayYear
Pick date from calendar!
The following three items are for the application but are not considered as sources of income. Include any amounts received from these three sources for {HH5Name}:
#5 Food Stamps
#5 Utility Check
#5 Section 8 or Income-base Housing
Please list GROSS income amounts of all types received in the last 30 days by Household Member #5:
#5 Employment:
Enter 0 if none
#5 Social Security:
Enter 0 if none
#5 Unemployment:
Enter 0 if none
#5 Child Support:
Enter 0 if none
#5 T. A. N. F.
Enter 0 if none
#5 OTHER:
Enter 0 if none
- If #5 OTHER, please explain:
- Household Member #5 Total Income:
- Is there another person in this household after Member #5:

Household Member #6 Information
Name of Household Member #6:

First NameLast Name
Date of Birth for Household Member #6:

MonthDayYear
Pick date from calendar!
The following three items are for the application but are not considered as sources of income. Include any amounts received from these three sources for {HH6Name}:
#6 Food Stamps
#6 Utility Check
#6 Section 8 or Income-base Housing
Please list GROSS income amounts of all types received in the last 30 days by Household Member #6:
#6 Employment:
Enter 0 if none
#6 Social Security:
Enter 0 if none
#6 Unemployment:
Enter 0 if none
#6 Child Support:
Enter 0 if none
#6 T. A. N. F.
Enter 0 if none
#6 OTHER:
Enter 0 if none
- If #6 OTHER, please explain:
- Household Member #6 Total Income:
- Is there another person in this household after Member #6:

Household Member #7 Information
Name of Household Member #7:

First NameLast Name
Date of Birth for Household Member #7:

MonthDayYear
Pick date from calendar!
The following three items are for the application but are not considered as sources of income. Include any amounts received from these three sources for {HH7Name}:
#7 Food Stamps
#7 Utility Check
#7 Section 8 or Income-base Housing
Please list GROSS income amounts of all types received in the last 30 days by Household Member #7:
#7 Employment:
Enter 0 if none
#7 Social Security:
Enter 0 if none
#7 Unemployment:
Enter 0 if none
#7 Child Support:
Enter 0 if none
#7 T. A. N. F.
Enter 0 if none
#7 OTHER:
Enter 0 if none
- If #7 OTHER, please explain:
- Household Member #7 Total Income:
- Is there another person in this household after Member #7:

Household Member #8 Information
Name of Household Member #8:

First NameLast Name
Date of Birth for Household Member #8:

MonthDayYear
Pick date from calendar!
The following three items are for the application but are not considered as sources of income. Include any amounts received from these three sources for {HH8Name}:
#8 Food Stamps
#8 Utility Check
#8 Section 8 or Income-base Housing
Please list GROSS income amounts of all types received in the last 30 days by Household Member #8:
#8 Employment:
Enter 0 if none
#8 Social Security:
Enter 0 if none
#8 Unemployment:
Enter 0 if none
#8 Child Support:
Enter 0 if none
#8 T. A. N. F.
Enter 0 if none
#8 OTHER:
Enter 0 if none
- If #8 OTHER, please explain:
- Household Member #8 Total Income:
- Is there another person in this household after Member #8:

Household Member #9 Information
Name of Household Member #9:

First NameLast Name
Date of Birth for Household Member #9:

MonthDayYear
Pick date from calendar!
The following three items are for the application but are not considered as sources of income. Include any amounts received from these three sources for {HH9Name}:
#9 Food Stamps
#9 Utility Check
#9 Section 8 or Income-base Housing
Please list GROSS income amounts of all types received in the last 30 days by Household Member #9:
#9 Employment:
Enter 0 if none
#9 Social Security:
Enter 0 if none
#9 Unemployment:
Enter 0 if none
#9 Child Support:
Enter 0 if none
#9 T. A. N. F.
Enter 0 if none
#9 OTHER:
Enter 0 if none
- If #9 OTHER, please explain:
- Household Member #9 Total Income:
- Is there another person in this household after Member #9:

Household Member #10 Information
Name of Household Member #10:

First NameLast Name
Date of Birth for Household Member #10:

MonthDayYear
Pick date from calendar!
The following three items are for the application but are not considered as sources of income. Include any amounts received from these three sources for {HH10Name}:
#10 Food Stamps
#10 Utility Check
#10 Section 8 or Income-base Housing
Please list GROSS income amounts of all types received in the last 30 days by Household Member #10:
#10 Employment:
Enter 0 if none
#10 Social Security:
Enter 0 if none
#10 Unemployment:
Enter 0 if none
#10 Child Support:
Enter 0 if none
#10 T. A. N. F.
Enter 0 if none
#10 OTHER:
Enter 0 if none
- If #10 OTHER, please explain:
- Household Member #10 Total Income:

Alternative Assistance
Can Additional Services Help You? (select one or more for referral)

Other

Documents for ElderCool Assistance

NO documents needed NOW so nothing needs selected but choose those you may have if further documentation required then Next.
Please select those that you can produce:

Submission - ElderCool Assistance

Click the Submit button to complete the application

Documents for OTHER Assistance

Note that we may ask for other documentation based on your situation.
Please select those that you can produce:

Submission - OTHER Assistance

Click the Submit button to complete the application

0:NOT Applicable

Selection UNAVAILABLE at this time

1:NOT Applicable

Selection UNAVAILABLE at this time
Since the Independence Utilities Online webpage

https://utilities.indepmo.org

is currently not accessible,

we are not able to process utilities for Independence, MO.

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Should be Empty:

Application Status

Application CLOSED

Air Conditioning Relief

Disposition

Accommodations

Climate Control

Release of Information and Privacy Policy

Disqualified - NO Release Agreement

Utility Designation

Household Information

Primary Household Contact Information

Primary Household Income

NO Primary Household Income

Additional Household Members

Household Member #2 Information

Household Member #3 Information

Household Member #4 Information

Household Member #5 Information

Household Member #6 Information

Household Member #7 Information

Household Member #8 Information

Household Member #9 Information

Household Member #10 Information

Alternative Assistance

ElderCool Survey

Documents for ElderCool Assistance

Submission - ElderCool Assistance

Documents for OTHER Assistance

Submission - OTHER Assistance

0:NOT Applicable

1:NOT Applicable

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