Resource United Assistance Request
United Way Bristol TN/VA
Client Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Household Information
Spouse/ Partner Name
First Name
Last Name
Spouse / Partner Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Other Adults in the Home Names/ DOB/ Income
Children's Names / DOB/ School Attending:
Employment
Employed?
*
YES
NO
SSI/SSDI
Type of Employment
*
Full Time
Part Time
Unemployed
Disabled
Employer Name
*
N/A If not employed
How long Employed:
*
Household Income
*
Ex. SSI $980/month + Work $200.00/month
Assistance
What Assistance are you needing?
*
Rent
Utilities
Food
Other
Please explain your situation (why you need help, how did this occur, How much is needed):
*
Ex. I lost my job and need XYZ to help because...
Additional Comments:
Release of Information
Read the Below PDF, and then Sign at the bottom if you agree. By applying your digital signature you are agreeing to the below ROI, and permitting UWB to share information in order to obtain services on your behalf. By
ROI- Review and Sign
By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature for the above Release of Information:
*
EX. First Middle Last Name
Please verify that you are human
*
I understand this is a request for assistance, and that assistance is NOT GUARANTEED, even if I am requested to submit further documentation.
*
I Understand
Submit
Should be Empty: