2025-26 Client Assistance Request

CRISIS ASSISTANCE REQUEST FORM

The Arc of Buncombe County is a nonprofit agency that serves people with intellectual and developmental disabilities (I/DD) in Western North Carolina.
Client (The "client" is the individual in the household with a diagnosed intellectual or developmental disability)*

First NameLast Name
If this client is not a minor (over 18) but you are a parent or guardian applying in their name, do you have legal guardianship over this client?
Client's Gender*
Client's Date of Birth*
Enter MM/DD/YYY
Last 4 numbers of the client's SS#*
School*
Client's Race - The following question is optional and used for statistical and reporting purposes only. Your response will not affect your eligibility for assistance.*
Client's Ethnicity - The following questions are optional and are used for statistical and reporting purposes only. Your response will not affect your eligibility for assistance.*
Diagnosis*
Type of Assistance Needed*

Housing AssistanceUtilityTransportationMedical
Explain Need/Request include dollar amount for that need here*
Explain briefly why this crisis is occurring (i.e., lost job, reduced hours). This is your opportunity to tell us your story. *
Parent/Guardian Information *

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (must be a working number for us to reach you)*
Please enter a valid phone number.
Last 4 of Parent/Guardian's SS# (put n/a if you are the client)*
Parent/Guardian's Date of Birth*
Enter MM/DD/YYY
Parent/Guardian's Gender*
Email*
example@example.com
County of Residence*
Parent/Guardian's Ethnicity - The following question is optional and used for statistical and reporting purposes only. Your response will not affect your eligibility for assistance.*
Parent/Guardian's Race - The following question is optional and used for statistical and reporting purposes only. Your response will not affect your eligibility for assistance.*
Marital Status
Employment*
Do you receive Medicaid? *
Answer Yes or No
Business/Company Name of Employment*
Total Monthly Household Income (wage, SSI, social security, retirement, etc)*
Total # Adults Living in Home*
Total # Children in Home*
I am aware that The Arc of Buncombe County provides financial assistance for crisis situations. Funds are generally distributed to a person or family once in a 6-month period, based on availability our funds. Checks are written to vendors only.*

I agree
I allow permission for The Arc to contact other community organizations regarding my request.

I agree
Is this a referral from another agency? If so, name of agency.*
IMPORTANT: *To process your application, we will need the application and all requested information included:
- Rental Assistance: copy of lease, landlord acceptance form, mortgage statement, eviction notice
- Auto Payment/Repairs: copy of auto insurance, copy of loan, copy of registration card, copy of current bill, copy of driver’s license
- Utility Payment: copy of most recent bill and copy of disconnect notice if applicable
- Other assistance: copy of quote or bill
The information I have provided above is true and accurate. I understand that misrepresentation or falsification of the information above could disqualify me from receiving funds.
Signature*

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Date*

MonthDayYear
Date

INCOME VERIFICATION

Please list your income, including wages, SSI, Social Security, Child Support, Retirement, etc.)
Name*

First NameLast Name
Please list the # of hours worked weekly. Enter 0 if none.*
Enter your gross pay weekly? Enter 0.00 if none.*
Phone Number*
Please enter a valid phone number.
Please list all income from the household: (SSA, SSI, SSDI, child support, retirement income, etc.). Please enter for example - $900 per month - Social Security Disability
Amount of income from SSA, SSI, SSDI, child support, etc.
Please List all income
Signature*

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Date

MonthDayYear
Date
NO INCOME/SUPPORT VERIFICATION

If you are NOT employed at this time, please complete this section.
Client/Parent/Guardian Name
Date of Last Employment
If you are not receiving any income from any source, we require the form to be signed!
Signature

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CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION
I, First Name* Last Name* the undersigned legally responsible person for Client Name* , do hereby consent and grant permission to The Arc of Buncombe County to advocate on behalf of Client Name* to gather and exchange information with any individuals or professionals representing agencies, schools, and local and state facilities pertaining to the welfare of the client.
Date*

MonthDayYear
Date
Signature*

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AUTHORIZATION TO USE WRITTEN MATERIALS/PHOTOGRAPHS

The purpose of this document is to give The Arc of Buncombe County permission to use images of me and/or the client in The Arc's promotional materials and social media sites.
I,   First Name*   Last Name* , hereby authorize The Arc, its employees, and those acting with its authorization, the right and permission to copyright, use, and/or publish videotape, photographic pictures or portraits of my images in The Arc's promotional materials, which includes but is not limited to, video productions, catalogs, magazines, brochures, public affairs releases, recruitment materials, as well as The Arc's website and other social media outlets, and other related endeavors. I hereby waive any right to inspect or approve the finished product containing my images.
I hereby release, discharge, and agree to hold harmless The Arc, its employees, or vendors (including any firm publishing and/or distributing the finished product) from and against any liability as a result of any distortion, blurring, or alteration of my images that may occur in the taking or editing the finished product, even should the same be regarded negatively in any way.
The authorization does not expire and may be withdrawn by me if I do so in writing to The Arc.
I have read this document and agree that I understand everything included in the document.
First Name*   Last Name*
Signature*

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CRISIS ASSISTANCE REQUEST FORM

INCOME VERIFICATION

NO INCOME/SUPPORT VERIFICATION

CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION

AUTHORIZATION TO USE WRITTEN MATERIALS/PHOTOGRAPHS