Bishop Sullivan Center Household Assistance Application

Application Status
Today's Date

MonthDayYear
Assistance Available:

ALL_TypesUtility_ONLY
Val-Sat
Val-Sun

Application CLOSED
Bishop Sullivan Center
NOT accepting applications!

Please check bishopsullivan.org for status update.

Bishop Sullivan Center Household Assistance Application
If you are coming to this site,
we know you are having financial stress.

Though we hope we can help you,
we do have guidelines
that we are obligated to follow.

Please take your time
reading our guidelines while
filling out the application.

If we are unable to assist you,
we hope you can find help elsewhere.
Priority Notification

Announcement for Significant Conditions
Bishop Sullivan Center will be CLOSED the following:

December 23, 2022 through January 02, 2023

In order to provide appropriate time to process all rental requests
before the end of the year, NO applications for:

Past Due Rent or
FIRST Month's Rent

will be accepted for the remainder of 2022.

ALL Household Assistance online applications will resume on

Tuesday - January 03, 2023.

Have a Merry Christmas and Happy New Year!

Memorandum of Understanding

Please initial each line item below, acknowledging that you have read and understand ALL statements in order to continue the application.
Initials* I understand assistance is limited to unplanned expenses from an unexpected event. (Job loss, health change, vehicle repair, etc.)
Initials* I understand NO assistance is provided for extreme, excessive, or recurring expenses. (Major house repair, vehicle purchase, multiple payments or ongoing need, etc.)
Initials* I understand required guidelines are set forth by the funder where approvals and denials for assistance are based on funds available at time of application.
Initials* I understand caseworkers must be good stewards of limited financial resources and only assist with minimal amounts so VERY LARGE balances due will be denied.
Initials* I understand it can take 5-10 business days to review an application. (Depends upon the current volume of submitted requests.)

Initials* I understand all Information I enter on the application will be accurate and any requested documentation that I provide MUST match that indicated in the application. (For example, a $213 car repair on application requires a written estimate for $213.)
Initials* I understand very large balances due will not be considered so this large balance must be reduced BEFORE applying. (Inaccurately reported amounts will be denied.)
Initials* I understand mutual respect between the caseworker and myself is expected. (ANY profanity, verbal/physical threats, and raised voices will be denied assistance.)
Initials* I understand I must check my emails and/or voicemails and respond in a timely manner to any communication efforts from the caseworker.
Initials* I understand nearly all cases will require I provide some type of copayment.

Residing Status

We are currently assisting Missouri households residing in Clay and Jackson Counties (excluding eastern Jackson County cities of Buckner, Grain Valley, Greenwood, Lake Lotawana, Lake Tapawingo, Levasy, Lone Jack, Oak Grove, and Sibley) (unless you were referred by one of our organizational partners).
Are you currently homeless or housed?*

HousedHomeless

Past Revenue
Have you received income in the past 60 days?*

YesNo

Disqualified - NO income last 60 days
Bishop Sullivan Center is only able to help those
who have received income in the past 60 days.

If you are looking for help finding a job,
you can contact our Employment Services program
at 816-231-0984
to schedule a meeting with a job counselor.

You can contact United Way of Greater Kansas City
who provides information of other agencies
that may be able to offer assistance to you
by calling 2-1-1
or visiting https://www.unitedwaygkc.org/get-help

Disqualified - BSC Assistance in last 13 months
Bishop Sullivan Center is NOT able to help those who have
received assistance from our agency in the past 13 months.

You can contact United Way of Greater Kansas City
who provides information of other agencies
that may be able to offer assistance to you
by calling 2-1-1
or visiting https://www.unitedwaygkc.org/get-help

Income Guidelines

Please note: Gross Income = the amount of your income before taxes are taken out. Example: Your monthly salary is $1,500, but you receive a $1,200 check. Your Gross Income is $1,500.
185% Poverty Guidelines for Number in Household
Including yourself, how many are living in your household?*
Example 1: You, two children and three other adults = 6 total in household. Example 2: You are the only one in your household = 1 total in household
Given the total number of individuals living in your household and based on the previous table, do you fall under 185% of the Federal Poverty Level?*

YesNo

Disqualified - NOT Under Income Guidelines
Bishop Sullivan Center is only able to help those
within the specified income guidelines.

If you are looking for help finding a job,
you can contact our Employment Services program
at 816-231-0984
to schedule a meeting with a job counselor.

You can contact United Way of Greater Kansas City
who provides information of other agencies
that may be able to offer assistance to you
by calling 2-1-1
or visiting https://www.unitedwaygkc.org/get-help

Release of Information and Privacy Policy
The information I provide is true and correct. I understand that my information is electronically tracked through MAACLink in order to assess my household needs and provide better services such as housing, utility assistance, food, and other services. My information may be shared among the agencies from which I have requested emergency assistance or case management. If I am applying for utility or rent/lease assistance, my information will be shared with my utility or landlord/leasing company by phone, email, or in written form in order to process the application and secure payment to the correct account. Donors are often shared stories without giving identifying information. These stories are impactful to further our ability to provide funding.*

I agreeI do not agree
Signature*

Clear

Disqualified - NO Release Agreement
Bishop Sullivan Center is only able to help when
you agree to the Release of Information and Privacy Policy.

You can contact United Way of Greater Kansas City
who provides information of other agencies
that may be able to offer assistance to you
by calling 2-1-1
or visiting https://www.unitedwaygkc.org/get-help

Type of Assistance

Utility Type
Which utility bill are you needing assistance with?*

ElectricGasWater

Utility Designation
Is this {UtlTyp} Utility listed in your name?*

YesNo

Disqualified - NOT Listed on Utility
Bishop Sullivan Center is only able to help when
the utility is in the name of the person applying.

You can contact United Way of Greater Kansas City
who provides information of other agencies
that may be able to offer assistance to you
by calling 2-1-1
or visiting https://www.unitedwaygkc.org/get-help

Disqualified - Exceeds Utility Limit
The current balance due is too much beyond the Bishop Sullivan Center assistance of minimal amounts. After this very large balance due is reduced, please re-apply with the new accurate amounts.

You can contact United Way of Greater Kansas City
who provides information of other agencies
that may be able to offer assistance to you
by calling 2-1-1
or visiting https://www.unitedwaygkc.org/get-help

Utility Status
What is the status of this {UtlTyp} Service?*

Utility is ON but NO Threat of DisconnectionUtility is ON and I have received a Disconnect NoticeDISCONNECTED

Disqualified - NO Disconnect Notice
Bishop Sullivan Center is only able to help
when a disconnection notice has been received.

You can contact United Way of Greater Kansas City
who provides information of other agencies
that may be able to offer assistance to you
by calling 2-1-1
or visiting https://www.unitedwaygkc.org/get-help

Disqualified - Disconnection over 90 days
Bishop Sullivan Center is only able to help when
utility disconnection is within the past 90 days.

You can contact United Way of Greater Kansas City
who provides information of other agencies
that may be able to offer assistance to you
by calling 2-1-1
or visiting https://www.unitedwaygkc.org/get-help

Utility Payments - Last 90 days
Have you made a payment over $25 in the past 90 days?*

YesNo

Disqualified - NO Utility Payment last 90 days
Bishop Sullivan Center is only able to help if you have made
a payment over $25 on this utility within the last 90 days.

You can contact United Way of Greater Kansas City
who provides information of other agencies
that may be able to offer assistance to you
by calling 2-1-1
or visiting https://www.unitedwaygkc.org/get-help

Past Due Lease/Rental Designation
Have you received RENTAL assistance from our agency in the last 24 months?*

YesNo

Disqualified - Housing Subsidized
Bishop Sullivan Center is only able to help
when the rent/lease is NOT subsidized.

You can contact United Way of Greater Kansas City
who provides information of other agencies
that may be able to offer assistance to you
by calling 2-1-1
or visiting https://www.unitedwaygkc.org/get-help

Disqualified - NOT Listed on Agreement
Bishop Sullivan Center is only able to help when the
rent/lease is in the name of the person applying.

You can contact United Way of Greater Kansas City
who provides information of other agencies
that may be able to offer assistance to you
by calling 2-1-1
or visiting https://www.unitedwaygkc.org/get-help

Disqualified - Rental Assistance in last 24 months
Bishop Sullivan Center is NOT able to help those who have
received RENTAL assistance from our agency in past 24 months.

You can contact United Way of Greater Kansas City
who provides information of other agencies
that may be able to offer assistance to you
by calling 2-1-1
or visiting https://www.unitedwaygkc.org/get-help

Past Due Lease/Rental Information
Name of Landlord or Financial Institution:*
Telephone of Landlord or Financial Institution:*
Email of Landlord or Financial Institution:
IF Available (such as example@example.com)
Amount due each month:*
Date you moved in:*

MonthDayYear
Pick date from calendar!

Disqualified - Move In Under 6 months
Bishop Sullivan Center is only able to help when
you have lived in this housing for more than 6 months.

You can contact United Way of Greater Kansas City
who provides information of other agencies
that may be able to offer assistance to you
by calling 2-1-1
or visiting https://www.unitedwaygkc.org/get-help

Past Due Lease/Rental Context
Past Due Amount Owed:*
How much can you pay towards this Past Due Amount?*

Disqualified - Exceeds Past Due Limit
The current balance due is too much beyond the Bishop Sullivan Center assistance of minimal amounts. After this very large balance due is reduced, please re-apply with the new accurate amounts.

You can contact United Way of Greater Kansas City
who provides information of other agencies
that may be able to offer assistance to you
by calling 2-1-1
or visiting https://www.unitedwaygkc.org/get-help

Past Due Lease/Rental Last Payment

Full or Partial payment you have personally paid
Amount of last personal payment:*
Date of last personal payment:*

MonthDayYear
Pick date from calendar!

Disqualified - NO Past Due Payment in last 6 months
Bishop Sullivan Center is only able to help when a payment
on rent/lease has been made within the past 6 months.

You can contact United Way of Greater Kansas City
who provides information of other agencies
that may be able to offer assistance to you
by calling 2-1-1
or visiting https://www.unitedwaygkc.org/get-help

Past Due Lease/Rental Notification

Please indicate how you were notified
Are you at risk of losing your current housing?*

Letter of DelinquencyEviction NoticeForeclosure ProceedingNone of the above

Disqualified - NO Past Due Notification
Bishop Sullivan Center is only able to help those who
have received notification of losing current housing.

You can contact United Way of Greater Kansas City
who provides information of other agencies
that may be able to offer assistance to you
by calling 2-1-1
or visiting https://www.unitedwaygkc.org/get-help

FIRST Month's Lease/Rent Context
For persons experiencing homelessness,
we may be able to assist you
to move into your own place
with PART of first month's rent
but NO HELP WITH DEPOSITS.

Please note that we are NOT able to assist:
- IF you are NOT homeless
- IF you are wanting rent for motel/hotel
- IF you have ALREADY moved into your new housing
- IF you just are moving BETWEEN 2 addresses (leases)

You MUST be able to document
you have enough income
to pay your bills going forward.
As an adult, how many times have you been homeless?*
This latest time, how long have you been homeless?
Years*
Enter ZERO if LESS than a year
Months*
Enter ZERO if MORE than a year
Have you already completed a budget with your homeless case manager?*

YesNo
Is the Lease/Rental Application listed in YOUR name?*

YesNo

Disqualified - NOT Listed on Application
Bishop Sullivan Center can only offer assistance
IF the lease/rental application is in YOUR name.

You can contact United Way of Greater Kansas City
who provides information of other agencies
that may be able to offer assistance to you
by calling 2-1-1
or visiting https://www.unitedwaygkc.org/get-help

Disqualified - Application NOT Approved
Bishop Sullivan Center can only offer assistance
IF the lease/rental application has been APPROVED already.

You can contact United Way of Greater Kansas City
who provides information of other agencies
that may be able to offer assistance to you
by calling 2-1-1
or visiting https://www.unitedwaygkc.org/get-help

Disqualified - NO DEPOSIT Secured
Bishop Sullivan Center can only offer assistance
IF the DEPOSIT has been secured BEFORE move-in.

You can contact United Way of Greater Kansas City
who provides information of other agencies
that may be able to offer assistance to you
by calling 2-1-1
or visiting https://www.unitedwaygkc.org/get-help

FIRST Month's Lease/Rent Information
Name of Prospective Landlord:*
Telephone of Prospective Landlord:*
Email of Prospective Landlord:
IF Available (such as example@example.com)
Address APPROVED to move into:*

Street Address

Apartment/Suite/Office

CityState

Zip Code
Amount Due each month:*
Planned Move-In Date:*

MonthDayYear
Pick date from calendar!

FIRST Month's Lease/Rental Constraints
Do you have any outstanding back utility bills or charges affecting your ability to move in?*

YesNo
Please list all costs required to Move-In:
Deposit:*
Enter 0 if none
First Month's Payment:*
Enter 0 if none
If applies, Last Month's Payment:*
Enter 0 if none
Transportation & Equipment:*
Enter 0 if none
Materials (boxes, tape, padding, etc.):*
Enter 0 if none
OTHER:*
Enter 0 if none

Auto/Vehicle Repair Validation
How much do you think the vehicle repair will cost?*

Disqualified - Exceeds Auto/Vehicle Repair Limit
The Amount for Repairs exceeds the limit of what
Bishop Sullivan Center is able to help with for Auto/Vehicle Repair.

You can contact United Way of Greater Kansas City
who provides information of other agencies
that may be able to offer assistance to you
by calling 2-1-1
or visiting https://www.unitedwaygkc.org/get-help

Disqualified - NO Valid Driver's License
Bishop Sullivan Center can only offer assistance
if you have a valid driver's license.

You can contact United Way of Greater Kansas City
who provides information of other agencies
that may be able to offer assistance to you
by calling 2-1-1
or visiting https://www.unitedwaygkc.org/get-help

Disqualified - NO Valid Registration/Tags
Bishop Sullivan Center can only offer assistance
if vehicle registration/tags are valid in your name.

You can contact United Way of Greater Kansas City
who provides information of other agencies
that may be able to offer assistance to you
by calling 2-1-1
or visiting https://www.unitedwaygkc.org/get-help

Disqualified - NO Valid Insurance
Bishop Sullivan Center can only offer assistance
if vehicle has valid insurance in your name.

You can contact United Way of Greater Kansas City
who provides information of other agencies
that may be able to offer assistance to you
by calling 2-1-1
or visiting https://www.unitedwaygkc.org/get-help

Auto/Vehicle Repair Information
Vehicle condition to get to repair shop:*

Able to Drive thereNeeds to be Towed
Do you have a Written Estimate of Total Costs from an Established Repair Shop?*

YesNo

OLD Utility Bill Validation
ONLY when an OLD Utility bill has been
OUT OF SERVICE OVER 90 DAYS,
we can consider assisting you:

- IF you are HOMELESS
- IF you are ready to move immediately
- IF this OLD Utility Bill is preventing move-in
Which of the following documents can you provide?*

Housing VoucherNEW Rental/Lease AgreementMove-In/Welcome Letter from NEW LandlordNone of the above

Disqualified - NO Move-In Confirmation
Bishop Sullivan Center can only offer assistance
if you have documented confirmation of move-in.

You can contact United Way of Greater Kansas City
who provides information of other agencies
that may be able to offer assistance to you
by calling 2-1-1
or visiting https://www.unitedwaygkc.org/get-help

Disqualified - Exceeds OLD Utility Bill Limit
The current balance due is too much beyond the Bishop Sullivan Center assistance of minimal amounts. After this very large balance due is reduced, please re-apply with the new accurate amounts..

You can contact United Way of Greater Kansas City
who provides information of other agencies
that may be able to offer assistance to you
by calling 2-1-1
or visiting https://www.unitedwaygkc.org/get-help

Disqualified - NO Utility Payment last 90 days
Bishop Sullivan Center is only able to help if you have made
a payment over $25 on this OLD utility within the last 90 days.

You can contact United Way of Greater Kansas City
who provides information of other agencies
that may be able to offer assistance to you
by calling 2-1-1
or visiting https://www.unitedwaygkc.org/get-help

OLD Utility Bill Information
Which OLD Utility Bill are you needing assistance with?*

ElectricGasWater
What is the Utility Company for this OLD Utility Bill?*
What is this OLD Utility Bill Account Number?*

0/20
How much have you raised to resolve this OLD Utility Bill?*

OTHER Assistance

(NOT Assistance for Utility, Rent, or Deposit)
If Utility or Rent Assistance is needed, please return to

https://www.bishopsullivan.org/get-help/household-assistance

and choose the appropriate selection.

This OTHER category is intended for help not listed
in the previous choices of Type of Assistance.
DO NOT use OTHER for Utility, Rent, or Deposit
since it will be DENIED AUTOMATICALLY.
What are you needing help with?*
How much does this cost?*
How much money are you able to contribute to this cost?*
What other resources have you pursued in order to get help with this matter?*
Bishop Sullivan Center staff often conduct a home visit as part of the approval process for this type of assistance. Would you be willing to let staff visit your home?*

YesNo

Household Information
Provide the names and dates of birth for
all adults and all children in this household.
Include any income sources and amounts
each person contributed to the entire household
in the last 30 days.

Note: Enter the gross monthly income
(the actual amount received before taxes)
for the last 30 days.
Please do not estimate but
enter the actual amounts and
include all sources that apply.

Primary Household Contact Information
Primary Contact Name:*

First NameLast Name
Primary Contact Date of Birth:*

MonthDayYear
Pick date from calendar!
Primary Contact Street Address: (Current)*

Street Address

Apartment/Suite/Office

CityState

Zip Code
Provide a telephone number and/or e-mail address at which you can be contacted:*

Telephone Number OnlyE-mail Address OnlyBoth Telephone & E-mail

Primary Household Income
The following three items are for the application but are not considered as sources of income. Include any amounts received from these three sources for {HH1Name}:
#1 Food Stamps
#1 Utility Check
#1 Section 8 or Income-base Housing
Please list GROSS income amounts of all types received in the last 30 days by {HH1Name}:
#1 Employment:*
Enter 0 if none
#1 Social Security:*
Enter 0 if none
#1 Unemployment:*
Enter 0 if none
#1 Child Support:*
Enter 0 if none
#1 T. A. N. F.*
Enter 0 if none
#1 OTHER:*
Enter 0 if none

NO Primary Household Income
NO sources of income have been indicated in the last 30 days. Please explain how expenses have been met in the last 30 days.*

(25-100 words)0/999

Additional Household Members
Is there another person in the household after {HH1Name}?*

YesNo

Household Member #2 Information
Name of Household Member #2:*

First NameLast Name
Date of Birth for Household Member #2:*

MonthDayYear
Pick date from calendar!
The following three items are for the application but are not considered as sources of income. Include any amounts received from these three sources for {HH2Name}:
#2 Food Stamps
#2 Utility Check
#2 Section 8 or Income-base Housing
Please list GROSS income amounts of all types received in the last 30 days by Household Member #2:
#2 Employment:*
Enter 0 if none
#2 Social Security:*
Enter 0 if none
#2 Unemployment:*
Enter 0 if none
#2 Child Support:*
Enter 0 if none
#2 T. A. N. F.*
Enter 0 if none
#2 OTHER:*
Enter 0 if none

Household Member #3 Information
Name of Household Member #3:*

First NameLast Name
Date of Birth for Household Member #3:*

MonthDayYear
Pick date from calendar!
The following three items are for the application but are not considered as sources of income. Include any amounts received from these three sources for {HH3Name}:
#3 Food Stamps
#3 Utility Check
#3 Section 8 or Income-base Housing
Please list GROSS income amounts of all types received in the last 30 days by Household Member #3:
#3 Employment:*
Enter 0 if none
#3 Social Security:*
Enter 0 if none
#3 Unemployment:*
Enter 0 if none
#3 Child Support:*
Enter 0 if none
#3 T. A. N. F.*
Enter 0 if none
#3 OTHER:*
Enter 0 if none

Household Member #4 Information
Name of Household Member #4:*

First NameLast Name
Date of Birth for Household Member #4:*

MonthDayYear
Pick date from calendar!
The following three items are for the application but are not considered as sources of income. Include any amounts received from these three sources for {HH4Name}:
#4 Food Stamps
#4 Utility Check
#4 Section 8 or Income-base Housing
Please list GROSS income amounts of all types received in the last 30 days by Household Member #4:
#4 Employment:*
Enter 0 if none
#4 Social Security:*
Enter 0 if none
#4 Unemployment:*
Enter 0 if none
#4 Child Support:*
Enter 0 if none
#4 T. A. N. F.*
Enter 0 if none
#4 OTHER:*
Enter 0 if none

Household Member #5 Information
Name of Household Member #5:*

First NameLast Name
Date of Birth for Household Member #5:*

MonthDayYear
Pick date from calendar!
The following three items are for the application but are not considered as sources of income. Include any amounts received from these three sources for {HH5Name}:
#5 Food Stamps
#5 Utility Check
#5 Section 8 or Income-base Housing
Please list GROSS income amounts of all types received in the last 30 days by Household Member #5:
#5 Employment:*
Enter 0 if none
#5 Social Security:*
Enter 0 if none
#5 Unemployment:*
Enter 0 if none
#5 Child Support:*
Enter 0 if none
#5 T. A. N. F.*
Enter 0 if none
#5 OTHER:*
Enter 0 if none

Household Member #6 Information
Name of Household Member #6:*

First NameLast Name
Date of Birth for Household Member #6:*

MonthDayYear
Pick date from calendar!
The following three items are for the application but are not considered as sources of income. Include any amounts received from these three sources for {HH6Name}:
#6 Food Stamps
#6 Utility Check
#6 Section 8 or Income-base Housing
Please list GROSS income amounts of all types received in the last 30 days by Household Member #6:
#6 Employment:*
Enter 0 if none
#6 Social Security:*
Enter 0 if none
#6 Unemployment:*
Enter 0 if none
#6 Child Support:*
Enter 0 if none
#6 T. A. N. F.*
Enter 0 if none
#6 OTHER:*
Enter 0 if none

Household Member #7 Information
Name of Household Member #7:*

First NameLast Name
Date of Birth for Household Member #7:*

MonthDayYear
Pick date from calendar!
The following three items are for the application but are not considered as sources of income. Include any amounts received from these three sources for {HH7Name}:
#7 Food Stamps
#7 Utility Check
#7 Section 8 or Income-base Housing
Please list GROSS income amounts of all types received in the last 30 days by Household Member #7:
#7 Employment:*
Enter 0 if none
#7 Social Security:*
Enter 0 if none
#7 Unemployment:*
Enter 0 if none
#7 Child Support:*
Enter 0 if none
#7 T. A. N. F.*
Enter 0 if none
#7 OTHER:*
Enter 0 if none

Household Member #8 Information
Name of Household Member #8:*

First NameLast Name
Date of Birth for Household Member #8:*

MonthDayYear
Pick date from calendar!
The following three items are for the application but are not considered as sources of income. Include any amounts received from these three sources for {HH8Name}:
#8 Food Stamps
#8 Utility Check
#8 Section 8 or Income-base Housing
Please list GROSS income amounts of all types received in the last 30 days by Household Member #8:
#8 Employment:*
Enter 0 if none
#8 Social Security:*
Enter 0 if none
#8 Unemployment:*
Enter 0 if none
#8 Child Support:*
Enter 0 if none
#8 T. A. N. F.*
Enter 0 if none
#8 OTHER:*
Enter 0 if none

Household Member #9 Information
Name of Household Member #9:*

First NameLast Name
Date of Birth for Household Member #9:*

MonthDayYear
Pick date from calendar!
The following three items are for the application but are not considered as sources of income. Include any amounts received from these three sources for {HH9Name}:
#9 Food Stamps
#9 Utility Check
#9 Section 8 or Income-base Housing
Please list GROSS income amounts of all types received in the last 30 days by Household Member #9:
#9 Employment:*
Enter 0 if none
#9 Social Security:*
Enter 0 if none
#9 Unemployment:*
Enter 0 if none
#9 Child Support:*
Enter 0 if none
#9 T. A. N. F.*
Enter 0 if none
#9 OTHER:*
Enter 0 if none

Household Member #10 Information
Name of Household Member #10:*

First NameLast Name
Date of Birth for Household Member #10:*

MonthDayYear
Pick date from calendar!
The following three items are for the application but are not considered as sources of income. Include any amounts received from these three sources for {HH10Name}:
#10 Food Stamps
#10 Utility Check
#10 Section 8 or Income-base Housing
Please list GROSS income amounts of all types received in the last 30 days by Household Member #10:
#10 Employment:*
Enter 0 if none
#10 Social Security:*
Enter 0 if none
#10 Unemployment:*
Enter 0 if none
#10 Child Support:*
Enter 0 if none
#10 T. A. N. F.*
Enter 0 if none
#10 OTHER:*
Enter 0 if none

TWO Very Important Questions
The next two questions are very important
for the success of your application.

Most applications are denied because these
two questions are not answered thoroughly.

Additional documentation is expected in order
to support particular circumstances in your explanations.
(Police reports, receipts for funeral costs, vehicle repairs, etc.)

Take your time in answering them.

Please be as thorough as possible.

Reason for situation
Please select the reason that is most applicable to your current situation:*

Unexpected job lossUnexpected illnessUnexpected expenseOTHER (give detailed explanation below)
Provide details explaining why you are requesting assistance from Bishop Sullivan Center:

• Example 1: "I work full-time. I got sick and missed three days from work without pay. This happened at the beginning of August. I have proof from a doctor and I have documentation from my employer." (Documentation could be a check stub or a letter on letterhead showing missed time)

• Example 2: "I lost my job on (mm/dd/yyyy). I have applied for unemployment and I am waiting on my first payment. I'll be receiving $320 a week." (With this explanation, your plan for recovery is very important)

• Example 3: "I had to fix my car last week. It cost $200. I have receipts to show the cost of the repairs. Needing to have my car repaired, also impacted my transportation to work. I had to pay out additional money to my co-workers for gas."

• Poor Example: "Ran short of money."
Reason explanation must be at least 25 words:*

(25-999 words)0/999

Recovery from situation
Please select the financial recovery plan that is most applicable to your current situation:*

Returning to workHealth restoredUnexpected expense resolvedOTHER (give detailed explanation below)
Provide details explaining your plan to financially recover beyond your current situation:

• Example: "I was just offered a new job at Walmart as a cashier. I will be starting on mm/dd/yyyy and I can show my job offer as proof."

• Poor Example: "Get more money"
Recovery answer must be at least 25 words:*

(25-999 words)0/999
What Services Can Help You Achieve This Recovery: (select one or more for referral)*

Employment AssistanceFood AssistanceMedical AssistanceNone at this timeOther (list below)

Submits Today
Documents Checklist

We will require you to provide specific documents in order to assist you.
ProcTypAsst
ProcAsstTypHmlss

Documents for Utility Assistance

Note that we may ask for other documentation based on your situation.
Please select those that you can produce:

Copy of the latest {UtlTyp} bill with disconnect notice or final bill with disconnection date.Valid Picture IDSocial Security card (or birth certificate) for you and for every member of the householdProof of current address (e.g. Lease/Rental Agreement, Tax Receipt, other Utility Bill, etc.)Proof of income (e.g. award letter, child support, recent pay stub, Social Security benefits, etc.)Supporting documentation for particular circumstances (Police report, receipts for funeral cost, vehicle repairs, etc.)

Submission - Utility Assistance

Click the Submit button to complete the application

Documents for Past Due Rent/Lease Assistance

Note that we may ask for other documentation based on your situation.
Please select those that you can produce:

Copy of the Lease/Rental Agreement or MortgageCopy of Letter of Delinquency, Eviction Notice, or Foreclosure ProceedingValid Picture IDSocial Security card (or birth certificate) for you and for every member of the householdProof of current address (e.g. Lease/Rental Agreement, Tax Receipt, other Utility Bill, etc.)Proof of income (e.g. award letter, child support, recent pay stub, Social Security benefits, etc.)Supporting documentation for particular circumstances (Police report, receipts for funeral cost, vehicle repairs, etc.)

Submission - Past Due Rent/Lease Assistance

Click the Submit button to complete the application

Documents for FIRST Month's Rent Assistance

Note that we may ask for other documentation based on your situation.
Please select those that you can produce:

Copy of the Lease/Rental Application and/or supporting documentsValid Picture IDSocial Security card (or birth certificate) for you and for every member of the householdProof of income (e.g. award letter, child support, recent pay stub, Social Security benefits, etc.)Supporting documentation for particular circumstances (Homeless letter, Police report, receipts for funeral cost, vehicle repairs, etc.)

Submission - FIRST Month's Rent Assistance

Click the Submit button to complete the application

Documents for Auto/Vehicle Repair Assistance

Note that we may ask for other documentation based on your situation.
Please select those that you can produce:

Written estimate from established repair shop for total costsValid Driver's LicenseValid Vehicle RegistrationValid Vehicle InsuranceSocial Security card (or birth certificate) for you and for every member of the householdProof of income (e.g. award letter, child support, recent pay stub, Social Security benefits, etc.)Supporting documentation for particular circumstances (Homeless letter, Police report, receipts for funeral cost, etc.)

Submission - Auto/Vehicle Repair Assistance

Click the Submit button to complete the application

Documents for OLD Utility Bill Assistance

Note that we may ask for other documentation based on your situation.
Please select those that you can produce:

Copy of the OLD {OLDUtlTyp} bill with final notice of service or Utility Company Quote to allow service.Valid Picture IDSocial Security card (or birth certificate) for you and for every member of the householdProof of current address (e.g. Lease/Rental Agreement, Tax Receipt, other Utility Bill, etc.)Proof of income (e.g. award letter, child support, recent pay stub, Social Security benefits, etc.)Supporting documentation for particular circumstances (Police report, receipts for funeral cost, vehicle repairs, etc.)

Submission - OLD Utility Bill Assistance

Click the Submit button to complete the application

Documents for OTHER Assistance

Note that we may ask for other documentation based on your situation.
Please select those that you can produce:

Valid Picture IDSocial Security card (or birth certificate) for you and for every member of the householdProof of current address (e.g. Lease/Rental Agreement, Tax Receipt, other Utility Bill, etc.)Proof of income (e.g. award letter, child support, recent pay stub, Social Security benefits, etc.)Supporting documentation for particular circumstances (Police report, receipts for funeral cost, home repairs, etc.)

Submission - OTHER Assistance

Click the Submit button to complete the application

0:NOT Applicable

Selection UNAVAILABLE at this time

1:NOT Applicable

Selection UNAVAILABLE at this time
Since the Independence Utilities Online webpage

https://utilities.indepmo.org

is currently not accessible,

we are not able to process utilities for Independence, MO.

Heading
Should be Empty:

Application Status

Application CLOSED

Bishop Sullivan Center Household Assistance Application

Priority Notification

Memorandum of Understanding

Residing Status

Past Revenue

Disqualified - NO income last 60 days

Disqualified - BSC Assistance in last 13 months

Income Guidelines

Disqualified - NOT Under Income Guidelines

Referral Information

Release of Information and Privacy Policy

Disqualified - NO Release Agreement

Type of Assistance

Utility Type

Utility Designation

Disqualified - NOT Listed on Utility

Disqualified - Exceeds Utility Limit

Utility Status

Disqualified - NO Disconnect Notice

Disqualified - Disconnection over 90 days

Utility Payments - Last 90 days

Disqualified - NO Utility Payment last 90 days

Past Due Lease/Rental Designation

Disqualified - Housing Subsidized

Disqualified - NOT Listed on Agreement

Disqualified - Rental Assistance in last 24 months

Past Due Lease/Rental Information

Disqualified - Move In Under 6 months

Past Due Lease/Rental Context

Disqualified - Exceeds Past Due Limit

Past Due Lease/Rental Last Payment

Disqualified - NO Past Due Payment in last 6 months

Past Due Lease/Rental Notification

Disqualified - NO Past Due Notification

FIRST Month's Lease/Rent Context

Disqualified - NOT Listed on Application

Disqualified - Application NOT Approved

Disqualified - NO DEPOSIT Secured

FIRST Month's Lease/Rent Information

FIRST Month's Lease/Rental Constraints

Auto/Vehicle Repair Validation

Disqualified - Exceeds Auto/Vehicle Repair Limit

Disqualified - NO Valid Driver's License

Disqualified - NO Valid Registration/Tags

Disqualified - NO Valid Insurance

Auto/Vehicle Repair Information

OLD Utility Bill Validation

Disqualified - NO Move-In Confirmation

Disqualified - Exceeds OLD Utility Bill Limit

Disqualified - NO Utility Payment last 90 days

OLD Utility Bill Information

OTHER Assistance

Household Information

Primary Household Contact Information

Primary Household Income

NO Primary Household Income

Additional Household Members

Household Member #2 Information

Household Member #3 Information

Household Member #4 Information

Household Member #5 Information

Household Member #6 Information

Household Member #7 Information

Household Member #8 Information

Household Member #9 Information

Household Member #10 Information

TWO Very Important Questions

Reason for situation

Recovery from situation

Application Survey

Documents Checklist

Documents for Utility Assistance

Submission - Utility Assistance

Documents for Past Due Rent/Lease Assistance

Submission - Past Due Rent/Lease Assistance

Documents for FIRST Month's Rent Assistance

Submission - FIRST Month's Rent Assistance

Documents for Auto/Vehicle Repair Assistance