Application For Assistance

Application For Assistance

Utilities or Medicine
Date

MonthDayYear
Date
Applicant Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Demographics
Gender
Disabling condition?
Marital Status
Primary Language
Household Type

Other
Housing Type
Housing Structure
Home number of Stories
Dwelling Type
Do you live in
Year of Home Construction
If unknown, approximate age
Monthly Rent/Mortgage Amount
Smokers in Household?
If so, how many?
Was dwelling previously weatherized?
If so, when?
Other Contact Name

First NameLast Name
Other contact phone
Please enter a valid phone number.Format: (000) 000-0000.
Other contact relationship
Race
Ethnicity
All information, regarding an applicant or recipient, is confidential and may be disclosed only for purposes of determining eligibility providing services, or investigating suspected fraud in connection with the program. By signing this application, I authorize the Community Uplifting Alliance Project access to my household's fuel/utility/energy records pertaining to the eligibility of the applicant and for the purpose of any reporting required under Federal, State and local statutes regulations and ordinances.
I, Signature certify that all the above information is correct and may be used for household and income verification as well as zero income verification for statistical purposes. I authorize agency employees to contact any former employees and/or social services agencies to verify household income for the past thirty (30) days. I further certify that documentation to verify the same is included in the Applicant's official file/record...
Customer Signature
Date

MonthDayYear
Date
CUPA, its agent partners and funding sources do not discriminate on the basis of race, color sex, ae, religion, national origin, disability, or marital status. Your application will be properly reviewed to determine eligibility based on the required documents provided.

Application submitted on line must present proof of ID and evidence of provider bill statement for requested funds. Fund will be mailed to the provider.

Type a question

Rows	Income Source	Somewhat Satisfied	Satisfied	Any thoughts?
Friendliness

Should be Empty:

Application For Assistance

Demographics