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Specific Assistance Application

Contact Information

Household Members


Income Information

Do you receive?

List of Documents Needed For Assistance

 Please be Legible 

1. Proof of income:

*last 2 current pay stubs for anyone that lives in the household.

* If you receive any other supplemental income- AFDC, SS, SSI Food Stamps, Child
Support, Unemployment or other we will need document from showing the amount you
receive.

* If you are self-employed, you will need 2 bank statements showing the name
of the business. 

2. Proof of Residence:
* We will need another piece of mail to verify that you live at this address, Example: Gas,
Electric or Telephone Bill. It needs to be in your name or spouse. 

3. Proof of Who Lives In Household:
* We will need social security cards from everyone that lives in the household and picture
ID’s/DL of all adult applicants. If you do not have social security cards please go to the
Social Security Office and apply for one and bring us the letter to show that you have done
so. 

4. Assistance If Given For The Following:

*Rental: We need a letter from the landlord on letterhead with his/her name, Address
and phone number so that we can contact them. Letter must also state how much you pay
each month or how much you are past due. You must have proof that your balance is
not more than $200.00. Behind this page is a list of other resources you may call for assistance. 

* Utilities: Electric, Gas, Propane or Water (we will need the actual bill) 

* Lot/ House Payment: Letter from the lender or bank in which the note needs to be paid to (same as rental).

* Select All Files and Images at the same time

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