Assistance Application

  • Assistance Application

    Please fill out all required boxes
  • Date*
     - -
  • Date*
     - -
  • Format: (000) 000-0000.
  • Are you emplyed?*

  • Employer Information

  • Format: (000) 000-0000.
  • Marital Status*
  • What do you need assistance with the most?
  • Can you provide document proof for assistance?*
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  • Landlord/Rental Company Information

  • Format: (000) 000-0000.
  • Have you asked friends and/or 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)*
  • Is there someone we can contact to verify your assistance need(s)?*

  • Contact Information of individual that can verify your need(s)

  • Format: (000) 000-0000.
  • Are you willing to take financial classes if you require assistance more than 3x?*

  • I, *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.

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