Hope Network - Emergency Assistance Application

Hope Network Emergency Assistance Application
Please read carefully before you apply:

Welcome! If You need financial assistance, Hope Network may be able to help. The following information is crucial before you proceed with the application:

[1] Our primary area of service is Raytown, Missouri (includes Raytown School District).

[2] Up to $200 may be offered toward Emergency Assistance for Rent/Utilities/Vehicle Repair.

[3] Only one application per household will be considered within a twelve-month period (We can approve only once within 12 months).

[4] Filling this application does not guarantee approval for assistance.

***IF YOU AGREE & MEET THIS QUALICATION, PLEASE COMPLETE THE APPLICATION THOROUGHLY***

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I ackowledge the above information.*

YesNo

CONTACT INFORMATION
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What county do you live in?*
Jackson, Clay, Cass, etc.
Date of Birth*

MonthDayYear
Date
Have you received financial assistance from Hope Network within the last twelve months?*

YesNoDon't know / Not Sure

Household Information
Number of Household*
Additional Household Members (other than yourself, if applicable): ***Note: The number of people listed must reflect the number in household referenced above.
Housing Status*
What was your total household income over the last 30 days?*

Type of Assistance Needed

Due to the great need within our community and our limited resources, requests for Emergency Assistance may be limited to the Raytown Community. PLEASE NOTE THAT WE CAN HELP ONLY ONCE PER 12 MONTHS IF APPROVED. For Food & Clothing Pantry please visit: www.hopenetworkraytown.org.
What type of emergency assistance are you requesting?*

RentMortgageElectricNatural GasWaterSewerVehicle RepairOther
What is the dollar amount of assistance you are requesting?*
up to $200
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.

Emergency Assistance Details

Please fill in the following details accurately.
Rent Assistance

Please fill in the following details accurately. [Note: We DO NOT make personal payments. Payments are made only to the management/landlord]
Name of the Property Management/Landlord:*
Address of the Property Management/Landlord:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Contact Name:
Memo Line of the Check (Please include any information required by the management/landlord to be in the memo line)*
[Type "None/Not sure" if no information is available.]
Account Number:
[Please provide the rent account number, if applicable.]
Mortgage Assistance

Please fill in the following details accurately.
Name of the Lender:*
Address of the Lender:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Contact Name:
Memo Line of the Check (Please include any information required by the Lender to be in the memo line)*
[Type "None/Not sure" if no information is available.]
Account Number:*
Please upload the latest statement/delinquent notice.*

Browse Files

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Utility Assistance (Gas/Electric)

Please fill in the following details accurately.
Name of the Service Provider.*
Eg: Spire, Evergy, City of Raytown
Account Number:*
Please upload the latest bill/delinquent notice*

Browse Files

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Water Assistance

Please fill in the following details accurately.
Who is your Water service provider?*

Raytown Water (10017 E 63rd St)KC Water Dept. (*More details will be needed from you)Jackson County PWSD#2 (6945 Blue Ridge Blvd)Other
Account Number:*
Sewer Assistance

Please fill in the following details accurately.
Who is your Sewer service provider?*

City of Raytown SEWER (10000 E 59th St)KC Water Dept. (*More details will be needed from you)Jackson County PWSD#2 (6945 Blue Ridge Blvd)Other
Account Number:*
Vehicle Repair Assistance

Please fill in the following details accurately.
Year of the Vehicle*
Make & Model of Vehicle: (eg: Honda -Accord, Toyota -Corolla, Nissan -Versa) *

[Make][Model]
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.
Please upload the Estimate from the repair shop, if any.

Browse Files

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Document Upload
Please upload the latest bill /delinquent notice.*

Browse Files

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Client Consent & Release of Information

MID AMERICA ASSISTANCE COALITION (MAAC)
I hereby grant permission to HOPE NETWORK OF RAYTOWN to collect and enter my personal and household infromation into the MAAC-Link computer system (in order to be eligible for the KC Water Service Fund/assistance).

I Understand that MAACLink is used by other agencies for the purpose of:

1) Accurately assessing the needs of low-income, homeless or other special- needs individual in order to better assist them in improving their current/future situations.

2) Improving the quality of care and service for those in need in addition to coordinating services between participating agencies.

3) Tracking the effectiveness of efforts to meet the needs of the people who have recieved assistance.

4) Reporting demographic data on an aggregate level that is not individually identified.

I understand that all Agency Representatives who use the MAACLink system have been specially trained in confidentially measures and have signed Statements of Confidentiality.

My Information may be shared with a third party (Utility Provider, Landlord etc) in order to process the service I have requested.

Signing (digitally) this form does not guarantee that I will recieve assistance.

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TYPE YOUR NAME (To Consent)*
Signature*

Clear
Date (today)*

MonthDayYear
mm-dd-yyyy

Submission:
Thank you for checking our application. Unfortunately, we are unable to proceed with your application. To continue, kindly go back and acknowledge the given information.

May God's Grace and Peace be with You!
Thank you for your application. Once it has been submitted, Hope Network staff will review and respond to you whether it is approved/denied within 10 business days via email.

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.
Should be Empty:

Hope Network Emergency Assistance Application

CONTACT INFORMATION

Household Information

Type of Assistance Needed

Emergency Assistance Details

Rent Assistance

Mortgage Assistance

Utility Assistance (Gas/Electric)

Water Assistance

Sewer Assistance

Vehicle Repair Assistance

Document Upload

KCMO Water Service Fund*

Client Consent & Release of Information

Submission:

Thank you for checking our application. Unfortunately, we are unable to proceed with your application. To continue, kindly go back and acknowledge the given information.

Thank you for your application. Once it has been submitted, Hope Network staff will review and respond to you whether it is approved/denied within 10 business days via email.

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.