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  • PLEASE READ CAREFULLY!

    First State Community Action Agency does not and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, or military status, in any of its activities or operations.

  • This form is SECURE. Your information will be transmitted directly to our Intake Coordinator.

  • All individuals requesting service(s) from First State Community Action Agency MUST first provide basic information to verify your identity.  Once this registration process is complete, your information will be provided to the program(s) you select.  Some of our programs will require ADDITIONAL INFORMATION to determine your eligibility.  Eligibility for most assistance programs is based on household income and available funding.  Please be patient as we collect and verify this information. 

     Some of the services we offer require a REFERRAL from a State agency.  These services include:

    • Heater Repair/Replacement
    • State Rental Assistance Program
    • Grant Diversion Program

    If you are interested in any of these programs, please contact one of our offices for more information.

  • YOU MUST BE AT LEAST 18 YEARS OLD TO REGISTER!

    If you are NOT at least 18 years old, you must have your PARENT or GUARDIAN complete the registration and then ADD YOU AS A HOUSEHOLD MEMBER. If you a requesting services for a CHILD or other HOUSEHOLD MEMBER, you must ADD them to this application! Thank you!
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    • Registration

      Please select what PROGRAM(S) you are interested in:

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  • Additional Household Members

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  • Additional Household Members

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  • Additional Household Members

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  • Additional Household Members

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  • Additional Household Members

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  • Additional Household Members

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  • Additional Household Members

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  • If you have additional household members, please let your caseworker know. You will be provided a link to upload any additional documents.

  • I certify that the information provided is true to the best of my knowledge. I am aware that the information I have provided is subject to review and verification. I further understand that I must provide documents to support claims made in this application.  

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  • Thank you!

    Thank you for completing our application. Please click PRINT to print a copy of your application for your records then click SUBMIT to securely send your application to our Intake Coordinator. Someone will contact you within 2 business days.
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