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  • SHIM Financial Assistance Application

  • An application does not guarantee assistance will be provided. Emergency assistance applications made to South Hills Interfaith Movement are for residents of the South Hills in Allegheny County. Income limits apply.

  • In addition to this completed form, we will need the following documentation, including, but not limited to:

    • Driver's License/Photo ID
    • Income (all income for all household members age 18 or older over the last 30 day)
      • (Earned income, social security, disability, etc)
    • Documentation showing the expenses you would like help addressing:
      • Rental Agreement (must be current and include payment information and signatures)
      • Rent Ledger, or something showing current balance owed
      • Utility History (for the last 1 to 3 months)
      • Other expenses, based on your request for assistance


    If you are unable to attach your files to the end of this application, please reachout by email to assistance@shimcares.org.

    Other documentation, or a separate application, may be required to assess eligibility. We will contact you if other things are needed. 

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  • Self-declaration of income for individual and household with no income or with income at or under 200% FPL

    To be completed only if there is no income documenation or no income for the past 30 days

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  • If I selected either one of the above as a part of my eligibility determination, a redetermination of eligibility is required within 90 days. Before 90 days, if my household had eligible income for the 30-day period prior to my enrollment date, I will secure income documentation if possible.

    Name of individual to receive services: *
    Name(s) of other household members: *
    Total number of persons in household: *
    Signature of individual to receive services:         
    Date of signature for this form:* 

  • CONSENT FOR SHARED INFORMATION:

  • I, hereby give permission to South Hills Interfaith Movement to share my information and progress with funders, landlords or mortgage companies, utility companies, and other human service agencies on an as-needed basis. All information will be strictly confidential.

    • I release South Hills Interfaith Movement and its insurers from all liability, claims, causes of action, damages, cost expenses or demands of any kind which may arise in connection with my participation in the activities of the program.
    • I attest that the information provided is accurate and true to the best of my knowledge.
    •  I understand and accept that false/incomplete statements will result in denial of this application.  I understand that this application does not guarantee I will receive a grant nor does it guarantee that any particular amount of grant will be awarded."


    PARTICIPANT SIGNATURE:     
    DATE:

  • PROOF OF ALL INCOME AND EXPENSE DOCUMENTATION IS REQUIRED TO PROCESS THE APPLICATION AND RECEIVE ASSISTANCE

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  • Acknowledgement of Funding

     

    Our programs are funded in whole or in part by private funds or under the Community Services Block Grant (CSBG) from the Federal Department of Health and Human Services under the administration of the Commonwealth of Pennsylvania, Department of Community and Economic Development. Allegheny County Department of Human Services is the local agency which makes the CSBG funding award.

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