Client Assistance Application

Client Assistance Application

Please complete this form and submit for review. A caseworker will contact you.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Are you a US veteran?

YesNo
What kind of assistance are you applying for?*

Rent/MortgageUtilitiesBoth
Please explain what kind of assistance you are needing and the reason.*

PLEASE COMPLETE ONLY ONE SECTION BELOW.
- SECTION ONE IS TO BE COMPLETED IF YOU HAVE NOT RECEIVED AN INCOME IN THE LAST 30 DAYS.
- SECTION TWO IS TO BE COMPLETED IF YOU HAVE RECEIVED AN INCOME IN THE LAST 30 DAYS.
Self-Attestation for No Income in the Last 30 Days

SECTION ONE - COMPLETE IF YOU HAVE RECEIVED NO INCOME IN THE LAST 30 DAYS.
Iname certify that I have not been employed or self-employed (receiving earned income), completed any odd jobs, or had any other source of income (SSA/SSDI/SSI, child support, alimony, retirement income, etc.) in the last 30 days.

I attest that this statement about myself, to determine eligibility, is true and correct to the best of my knowledge.

Signature
Self-Attestation for Income in the Last 30 Days

SECTION TWO - COMPLETE IF YOU HAVE RECEIVED AN INCOME IN THE LAST 30 DAYS.
I have received this gross amount of income $ amountondate from business . Please provide documents to verify this information (pay stubs, etc.)
I attest that this statement about myself, to determine eligibility, is true and correct to the best of my knowledge.

Signature
For utility applicants, please upload a copy of your driver's license, your most recent bill showing past due amount, and proof of income (pay stubs, check copies, SSDI award letter, etc.) If you have not income, please be sure you completed the Attestation of No Income portion of the application above.

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For rent/mortgage applicants, please upload a copy of your driver's license, your rent agreement or most recent mortgage statement, and proof of income (pay stubs, check copies, SSDI award letter, etc.) If you have not income, please be sure you completed the Attestation of No Income portion of the application above.

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Please be sure that your landlord completes the landlord form as well. Your application is not complete until this is received.

Once your application is received and compete, you will be contacted by email and or a phone call to do a short interview.

Payments are made directly to the landlord/vendor on your behalf.
Should be Empty:

Client Assistance Application

Self-Attestation for No Income in the Last 30 Days

Self-Attestation for Income in the Last 30 Days