Assistance Application

Marital Status*

MarriedMarried with ChildrensingleWidow/WidowerSingle ParentElderly
How many dependents do you have?*
Children under the age of 18 that live in the home.. If you have none please type "0". Do not leave field blank.

What do you need assistance with the most?

RentWater BillElectric BillGas BillOther
Type amount needed

If you have more items that you need assistance with please type them below. If not then simply type "NO". ( Do not leave field blank)*
Type each item with a total after. Thank you.

You clicked "NO". Can you specify why you haven't asked friends/family for assistance?*

Have you spoken with the Company/Person you need assistance with about a payment plan. (If you click yes, we will be calling to ask for proof)*

YesNo

You clicked "NO" for asking the Company/Person about a payment plan. Please specify why you haven't done this. *

You clicked "NO" to providing someone's contact information that we can use to verify your need(s). Pleas specify why.*

Are you willing to take financial classes if you require assistance more than 3x?*

YesNo

You have selected not to share information with us that is required. We cannot help you at this time until you are willing/able to share the needed information with us. Thank you for reaching out. If there is a reason that you have chosen not to share the required information with us, please explain further so that we can review your application a second time. *

I, blanks*have answered the required fields to the best of my ability, and understand that my answers may or may not qualify me for assistance. I agree to schedule a meeting time if my application is approved. I also understand that my assistance will be posted anonymously on the Hope Center's social media to ask community to raise funds for my need(s) if my application is approved. I understand that there is a limit to how much assistance the Hope Center can provide at any given time due to resource limitations which may result in my application being denied.
Signature*

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