Hope Network Emergency Assistance Application
Please Read Before Continuing:
Welcome! If you need financial assistance, Hope Network may be able to help. Our primary area of service is Raytown, Missouri. Hope Network may offer up to $200 toward Emergency Assistance for Rent, Utilities, and Vehicle Repair. Applications will only be considered once within a twelve-month period and only one financial request per household. If you meet these qualifications, please complete the application thoroughly.
I have read the above information.
*
Yes
CONTACT INFORMATION
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
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Household Information
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What county do you live in?
*
Jackson, Clay, Cass, etc.
Date of Birth
*
-
Month
-
Day
Year
Date
Number of Household
*
eg:1, 2, 3, 4, 5 etc...
Additional Household Members (other than yourself, if applicable). Note: The number of people listed must reflect the number in household referenced above.
Housing Status
Please Select
Stably Housed - Rent
Stably Housed - Mortgage
At Risk of Homelessness
Homeless
Other
What was your total household income over the last 30 days?
*
Have you received financial assistance from Hope Network within the last twelve months?
*
Yes
No
Don't Know
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Type of Assistance Needed
Due to the great need within our community and limited resources, requests for Emergency Assistance may be limited to the Raytown Community. However, our Food and Clothing Pantry is available to residents of Jackson County, Missouri. For more info please visit: www.hopenetworkraytown.org.
What type of emergency assistance are you requesting?
*
Rent/Mortgage
Electric
Natural Gas
Water/Sewer
Vehicle Repair
Other
What is the dollar amount of assistance you are requesting?
*
up to $200
Please provide your reason for assistance and any additional, relevant information that may help our team process your application.
*
Note: Hope Network may or may not be able to assist with all the requests depending on the availability of recources.
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Rent or Mortgage Assistance
Please fill in the following details accurately.
Name of the Property Management/Landlord:
*
Address of the Property Management/Landlord:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Contact Name:
Please include any information required by the management/landlord to be in the memo line of the check.
*
Type "None/Not sure" if no information is available.
Account Number:
(Please provide the rent/mortgage account number, if any.)
Utility Assistance
Please fill in the following details accurately.
Name of Provider.
*
Eg: Spire, Evergy, City of Raytown
Account Number:
*
(Please provide the account number for the account you are requesting assistance with.)
Water/Sewer Assistance
Please fill in the following details accurately.
Who is your Water/Sewer provider?
*
Raytown SEWER (10000 E 59th St)
Raytown Water (10017 E 63rd St)
KC Water Dept. (4800E 63rd St)
Jackson County PWSD#2 (6945 Blue Ridge Blvd)
Other
Account Number:
*
Vehicle Repair
Please fill in the following details accurately.
Year of the Vehicle
*
Make & Model of the Vehicle:
*
eg: Honda, Accord
Please provide a brief description of necessary repairs. (If you are already working with a reputable service provider, please provide the business name and contact information.)
*
Note: Hope Network is unable to assist with body work repairs.
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Submission:
Thank you for your application. Once it has been submitted, Hope Network staff will review your information and respond within 10 business days.
May God's Grace and Peace be with You!
Thank you for your application. Unfortunately, we are unable to meet your request at this time as we can assist only once per household in a twelve-month period.
However, we would be happy to point you to some resources that might help you in the meantime. If you want us to email you those resources, kindly consent below & submit. May God's Grace and Peace be with you!
Consent:
Yes, I would like the resource emailed to me.
No, I do not want it at this time.
Submit
Should be Empty: