Covid-19 Assistance Application

List names, social security number, relationship, birthdate and sex for each member of the household.
Please provide a list of of all income, Salaries, Retirement, TANF/Ch.Supp. Unemployment, Disability
Please provide a list of of all expenses. Rent/Mortgage Electric, Water ,Gas (home) Food, Phone, Auto Payment, Auto Gasoline, Auto Insurance, Insurance (Life, Health), Cable, Furniture, Taxes / S.S.
Click or drag files to this area to upload. You can upload up to 7 files.
Please provide Supporting Documents Required: Rent/Mortgage/Utility bill, IRS form W-9 form from landlord or Mortgage holder, Copy of ID for everyone in the household over the age of 18, Last 4 pay stubs, Letter of loss of hours or loss of job due to COVID-19
The above information is true and accurate to the best of my knowledge and belief. I understand that false information could lead to denial of services or legal prosecution. I authorize the release of information to agencies and vendors necessary to reach a determination of assistance. Further, I acknowledge that my request for services is voluntary and I may withdraw such request at any time with no hindrance.

I agree to use the following funds for: rent, mortgage, utilities, or other needs due to the effects of the COVID-19 crisis.

All of the information I have provided above to the service provider is accurate, complete and current to the best of my knowledge, I authorize the release of information related to determining my eligibility for assistance, I attest that I have not received any other COVID 19 funds or assistance from the CARES Act (exception-Stimulus check).