Online Assistance Application Form

1
Application Version
2
Telephonic Intake Attendant Name
First Name
Last Name
3
Telephonic Intake Attendant Email
example@example.com
4
Intake Channel
5
Intake Start Time
Date
Month
Day
Year
11
1
2
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10
11
12
Hour
44
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Minutes
AM
AM
PM
6
Just a friendly reminder as you complete the application:

📝 At the end of the application, there will be a Notes box. Please use this space to share any additional information you think would be helpful for our interview and finance teams.

⏰ Before you begin, please ask the person about the timeline of their need. When do they need help?

If the need is sooner than our process allows, it may be best to let them know now and help direct them to another service provider that may be able to assist more quickly.

Thank you for helping us gather this information upfront. It will help make the application and review process much smoother.
7
Important Application Notice

Completion of this application does not guarantee assistance. All applications are reviewed for eligibility, available funding, duplication of benefits, documentation, household income, expenses, sustainability, and program requirements. Applicants must provide true and complete information. False, incomplete, altered, or misleading information may result in denial, repayment request, and/or referral for further review. The agency may contact landlords, utility companies, employers, agencies, and other parties to verify information provided.

Please note if you are needing financial assistance in 14 days or less
we will not be able to assist you.

!! IMPORTANT UPDATE - 9.28.26 !!

The Catholic Center of Concern in Huntsville is currently not accepting rental assistance applications. We have received a high volume of requests and cannot review new rental applications at this time.

If you already submitted an application and received a denial, you must wait six weeks from the date of your denial notice before reapplying. The six-week wait does not guarantee that rental assistance will be available when you reapply.

Thank you for your understanding.
8
By clicking 'YES' you understand that completing this application does not guarantee assistance in any form.* This field is required.
YESNO
9
Date of Request
Date
Month
Day
Year
10
Applicant Name* This field is required.
First Name
Last Name
11
Applicant Physical Address* This field is required.
Street Address
Apartment or Street Address Line 2
City
State / Province
Postal / Zip Code
United States
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
12
Please select which county in Alabama you live?* This field is required.
Madison County
Colbert County
Franklin County
Jackson County Lauderdale County Lawrence County
Limestone County
Madison County
Marshall County
Morgan County
13
Do you have a different mailing address from your physical address?* This field is required.
YESNO
14
Applicant Mailing Address
Street Address
Apt/Street Address Line 2
City
State
Zip Code
United States
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
15
Applicant Phone Number* This field is required.Mobile Phone Please
Area Code
Phone Number
16
Do you have an alternate phone number?* This field is required.
YESNO
17
Phone Number
Area Code
Phone Number
18
Applicant Email Address* This field is required.
example@example.com
19
What is your current marital status?* This field is required.
Single
Married
Separated
Divorced
Widowed
Unknown
20
What is the last 4 digits of your Social Security number?* This field is required.Example: 0000
21
What is your date of Birth* This field is required.
Date
Month
Day
Year
22
What is your preferred method of contact?* This field is required.
Email
Phone
23
What type of financial assistance are you requesting?* This field is required.
Utilities
Prescription
24
What is the amount of financial assistance being requested?* This field is required.Please type in a dollar amount. (Example $1,000)
25
Is there a court date, disconnect date, eviction date, or a deadline needed to be met for financial assistance to help?* This field is required.
YESNO
26
Which type of date or deadline do you have coming up where the financial assistance is needed by?
Court Date
Eviction Date
Disconnect Date
Deadline Date
Other
27
Please share the date for that need with us based on your previous answers.
Date
Month
Day
Year
28
Have you applied elsewhere for this same financial need?* This field is required.
YESNO
29
Please list the Agency/Ministry you have applied with and the amount you have asked for.
Agency Name
Financial Amount Requested
What approximate date did you receive the financial assistance. (Example: MM/DD/YYYY)
30
Have you requested assistance from Catholic Center of Concern of Huntsville in the past?* This field is required.
YESNO
31
Since you have requested assistance before, please list the estimated date you did, and how much assistance was given.
Enter the date above we assistance you (Example: MM/DD/YYYY)
Please list the amount we assisted you with above. (Example $1,000)
32
Has another agency/ministry/non-profit assisted you financially in the last 90 days?* This field is required.
YESNO
33
Please provide the name of the organization that assisted you financially, the amount of assistance, and the date the assistance was received.
Please type the name of the organization above
Please type the amount of financial assistance you were given (Example: $1,000)
Please type the approximate date assistance was received. (MM/DD/YYYY)
34
What has happened in the last 30 days that requires you to request financial assistance?* This field is required.Please make sure to include as much detail as possible for our reviewers & approvers.
Huge
Large
Normal
Small
Ok
Ok
35
Please share with us specifically what has changed about your financial status that would lead to you needing assistance.* This field is required.Please make sure to include as much detail as possible for our reviewers & approvers.
Huge
Large
Normal
Small
Ok
Ok
36
When did you last make a payment towards this bill/rent/cost, and how much did you pay?* This field is required.
Please list the date of the last payment you made towards this dept (Example MM/DD/YYY)
Please list the amount of the payment you made (Example: $1,000)
37
What is the current balance of your account your requesting assistance for? (Rent/Prescription/Utility)
38
How much are you currently able to pay right now towards this dept/bill/rent/utility etc?* This field is required.
(Example: $1,000)
39
Have you made any payment arrangements with the agency you owe?* This field is required.
YESNO
40
Please share with us the specific details of the payment arrangement you made with the agency you owePlease make sure to include as much detail as possible for our reviewers & approvers.
Huge
Large
Normal
Small
Ok
Ok
41
If you received financial assistance are you able to pay the bills that will follow the bill we assist you with?* This field is required.
YESNO
42
How will you be able to sustain the bills in the future if we are able to assist you now?Please make sure to include as much detail as possible for our reviewers & approvers.
Huge
Large
Normal
Small
Ok
Ok
43
How many other people live in your household?Do not include yourself. Include all adults and children who currently live with you.
Please Select
0
1
2
3
4
5
6
44
Household Member #1(This is for additional household member, not the applicant.)
Name (First Name Last Name)
Birthdate (Example: DD/MM/YYYY
Last 4 of their Social Security Number (Ex: 0000)
Please Select
Please Select
Spouse
Friend
Girlfriend
Boyfriend
Son
Daughter
Mother
Father
Relationship to Applicant
Monthly Income Amount (Example: $1,500)
Monthly Income Source
45
Household Member #2(This is for additional household member, not the applicant.)
Name (First Name Last Name)
Birthdate (Example: DD/MM/YYYY
Last 4 of their Social Security Number (Ex: 0000)
Please Select
Please Select
Spouse
Friend
Girlfriend
Boyfriend
Son
Daughter
Mother
Father
Relationship to Applicant
Monthly Income Amount (Example: $1,500)
Monthly Income Source
46
Household Member #3(This is for additional household member, not the applicant.)
Name (First Name Last Name)
Birthdate (Example: DD/MM/YYYY
Last 4 of their Social Security Number (Ex: 0000)
Please Select
Please Select
Spouse
Friend
Girlfriend
Boyfriend
Son
Daughter
Mother
Father
Relationship to Applicant
Monthly Income Amount (Example: $1,500)
Monthly Income Source
47
Household Member #4(This is for additional household member, not the applicant.)
Name (First Name Last Name)
Birthdate (Example: DD/MM/YYYY
Last 4 of their Social Security Number (Ex: 0000)
Please Select
Please Select
Spouse
Friend
Girlfriend
Boyfriend
Son
Daughter
Mother
Father
Relationship to Applicant
Monthly Income Amount (Example: $1,500)
Monthly Income Source
48
Household Member #5(This is for additional household member, not the applicant.)
Name (First Name Last Name)
Birthdate (Example: DD/MM/YYYY
Last 4 of their Social Security Number (Ex: 0000)
Please Select
Please Select
Spouse
Friend
Girlfriend
Boyfriend
Son
Daughter
Mother
Father
Relationship to Applicant
Monthly Income Amount (Example: $1,500)
Monthly Income Source
49
Household Member #6(This is for additional household member, not the applicant.)
Name (First Name Last Name)
Birthdate (Example: DD/MM/YYYY
Last 4 of their Social Security Number (Ex: 0000)
Please Select
Please Select
Spouse
Friend
Girlfriend
Boyfriend
Son
Daughter
Mother
Father
Relationship to Applicant
Monthly Income Amount (Example: $1,500)
Monthly Income Source
50
What is your current employment status?* This field is required.
Please Select
Employed
Unemployed
Self-Employed
Disabled
Retired
51
What is your employer's name?
52
What is your monthly employment income?
53
If unemployed, what was the last date you worked at your previous job?
Date
Month
Day
Year
54
If unemployed who was your last employer?
Name of company or individual worked for
55
How long did you work for your last employer?
Example: 5 years etc.
56
What was the reason your previous employment ended?Please iPlease make sure to include as much detail as possible for our reviewers & approvers.
Huge
Large
Normal
Small
Ok
Ok
57
Do you have an expected return to work date?
YESNO
58
What date do you plan to return to work?
Date
Month
Day
Year
59
Do you have other forms of income?* This field is required.Example: SSI/SSDI, Child Support, TANF, Unemployment, SNAP/Food Stamps, Pension, etc.
YESNO
60
Please select all other monthly income you receive.
SSI/SSDI
Child Support
TANF
Unemployment Payments
Pension
Food Stamps / SNAP
Other
61
What is your total Other Income monthly?
Example: $1,250
62
What is the total amount of food stamps/SNAP benefits you receive
Example: $900
63
What is the total amount of monthly income you receive including employment & other forms of income?* This field is required.
Example: $2,300
64
Please enter all monthly household expenses that apply* This field is required.Please place a zero in the fields you have no expenses for and total all amounts in the final box.
Amount
Rent/Mortgage Amount
Row 0, Column 0
Utility Amount Monthly
Row 1, Column 0
Car Payment
Row 2, Column 0
Car Insurance
Row 3, Column 0
Gas/Bus/Transportation
Row 4, Column 0
Internet
Row 5, Column 0
Medical Expenses/Prescriptions
Row 6, Column 0
Past Due Rent
Row 7, Column 0
Past Due Utilities
Row 8, Column 0
Phone Bill
Row 9, Column 0
Childcare Costs
Row 10, Column 0
Food Cost Paid by Applicant
Row 11, Column 0
Other Required Expenses
Row 12, Column 0
Rent/Mortgage Amount
Utility Amount Monthly
Car Payment
Car Insurance
Gas/Bus/Transportation
Internet
Medical Expenses/Prescriptions
Past Due Rent
Past Due Utilities
Phone Bill
Childcare Costs
Food Cost Paid by Applicant
Other Required Expenses
Amount
Row 0, Column 0
Amount
Row 1, Column 0
Amount
Row 2, Column 0
Amount
Row 3, Column 0
Amount
Row 4, Column 0
Amount
Row 5, Column 0
Amount
Row 6, Column 0
Amount
Row 7, Column 0
Amount
Row 8, Column 0
Amount
Row 9, Column 0
Amount
Row 10, Column 0
Amount
Row 11, Column 0
Amount
Row 12, Column 0
1 of 13
65
Are you currently receiving Section 8 rent assistance?* This field is required.
YESNO
66
Since you are receiving Section 8 benefits, please list your portion of the monthly rent and the section 8 portion in the fields below.
My Portion of Rent Responsibility. (Example: $100)
Section 8 Portion of Rent Responsibility. (Example: $1,500)
67
What is your rental property/landlord's name?If you are asking for assistance with your mortgage list your bank/lender's name here.
68
What is your Landlord/Property Manager's Address?If you have a mortgage, list bank/lender's address here.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
69
What is your Landlord's Phone Number?If you have a mortgage list the name of your bank/lender here.
Area Code
Phone Number
70
What is your Landlord's email address?If you have a mortgage, please list contact email for your bank/lender.
example@example.com
71
What is your Account/Tenant Number?If you have a mortgage you should be able to find this number on your statement.
72
Is your lease/rental/mortgage in your name?
YESNO
73
What is your account's monthly payment?Please make are to list the total monthly payment, not your portion if you are splitting the payment with other people.
74
How many months of payments do you owe?number only please.
75
What is the total dollar amount you are "past due"?
Example: $1500
76
Have you received an eviction notice in writing?
YESNO
77
Have you received a court date or writ in association with your past due rent/payments/mortgage?
YESNO
78
If yes what is your court date in association with your past due rent/payments/mortgage?
Date
Year
Month
Day
79
Will your landlord/bank/lender allow payments from third party on your behalf?
YES
NO
UNKNOWN
80
If yes, please type out any special or specific instruction they have given you that we would have to follow if we are able to assist you with this debt.
Huge
Large
Normal
Small
Ok
Ok
81
What utilities are you needing assistance with?Select all that apply
Electric
Water
Gas
82
What is your utility company name?
83
What is your utility company mailing address?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
84
What is your utility company telephone number?This should be the number to call for customer support.
Area Code
Phone Number
85
What is your utility account number?Make sure this is accurate. Any mistakes could result in a denial of assistance.
86
What is the full legal name associated with this utility bill(s) that you are needing assistance with?Please be accurate - any incorrect data could result in an application denial.
87
What is the total dollar amount that you are past due on your utilities payments?
Example: $1750
88
Have you received a disconnection notice for your utilities?
YESNO
89
If Yes, what date were you given for your disconnection?
Date
Year
Month
Day
90
What was the amount of the last full payment you made to your utilities?Please make sure this is the last full payment you made to bring your balance to zero.
91
What was the date you made this last full payment on your utilities?Please make sure this is the date of your last full payment that brought your utilities debt to zero.
Date
Year
Month
Day
92
Are you currently in a payment arrangement with your utility company?
YESNO
93
If so what are the details of your payment plan with the utility company?
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94
Please list the accurate medical names of the life threatening prescriptions you are needing assistance with?
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95
What is the total amount you are needing to acquire these prescriptions?
Example: $300
96
What is the name of the Pharmacy you get your prescriptions through?
97
What is the address of your regular pharmacy?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
98
What is the phone number you use to contact your pharmacy?
Area Code
Phone Number
99
What is your plan to pay next month's rent, utilities, and other required expenses for your household?* This field is required.Please take your time on this question. How you answer this question will have a direct impact on our ability to approve you for assistance. You must have a plan for your future financial provision, and sustainability for your household.
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100
What steps have you taken to increase your income, or reduce your household expenses?* This field is required.Please take your time on this question. How you answer this question will have a direct impact on our ability to approve you for assistance. You must have a plan for your future financial provision, and sustainability for your household.
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Ok
101
Is there anyone else in your household that will start to contribute financially?* This field is required.
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Ok
102
What other community resources, agencies, family or supports have you contacted for assistance during this time of need?* This field is required.It is important that you are transparent and honest with your answer. We will see every support beyond family you have contacted in our case management system. Please answer honestly.
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103
Is there anything else we should know about your current financial position? Any special circumstances we should know?Everything helps us as we have to meet certain requirements for approval of assistance. Take your time and share any detail you can with us.
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104
Below is a list of the documentation we will need for your application to be complete. Please check all documents you will attach on the next question.
Applicant Photo ID, Front & Back
Physical & Official proof of all household income
Lease, eviction notice, rent ledger, bank, or landlord statements
Utility Bill or Disconnect Notice
Proof of expenses listed on this application
Proof of payment made by applicant, if applicable
Bank Statement or Transaction history
None - I will bring proof of the above documents at application interview.
105
Attach all the files you checked in the previous question that you have available.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
106
By submitting this application, I authorize Catholic Center of Concern in Huntsville to enter and store the information I provide in Charity Tracker and share it with participating organizations to review my request, coordinate assistance, document assistance requests and services, and avoid duplication of assistance. I certify that the information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that I must report all household income, household members, expenses, resources, and assistance received or pending from any other agency. I understand that Catholic Center of Concern in Huntsville may verify the information provided and may deny assistance if information is incomplete, false, unverifiable, or if funding/program requirements are not met. I understand that assistance is not guaranteed.* This field is required.
107
THIS IS FOR INTAKE TEAM MEMBER USE ONLYUse this space to add any additional or helpful notes for the rest of the team.
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Important Application Notice