Coalition of Powhatan Churches - NonProfit Organization Powhatan Virginia

Assistance Application

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Number of Persons in Home *

Email *

Individuals in the home, including yourself: Names, DOB, Gender, Relationship to Applicant, Education Level, SSN for each person *

Names, DOB, Gender, Relationship to Applicant, Education Level, SSN for each person. (Continued) *

Names, DOB, Gender, Relationship to Applicant, Education Level, SSN (Continued) *

Type of Account, Name of Bank, Account Balance *

Describe the recent change in circumstances: *

Check type of Assistance requested: *

Utility Mortgage/Rent Oil/Propane/Kerosene Other

Write the account numbers and phone numbers of all utilities/rent/oil, etc. *

Does your family currently receive SNAP or food stamps? *

Yes No Case Pending

What is your monthly mortgage/rental payment per month? *

Demographic information used for reporting purposes only:

(Demographic information used for reporting purposes only).
Ethnicity of all individuals in household *

Hispanic Not Hispanic Other

Race of Family *

Black/African American White Other

Does your family have Health Insurance? *

Yes No

If only some members have insurance, list who: *

Is anyone in the home declared legally disabled: *

Yes No

If yes, who? *

PLEASE READ THE FOLLOWING STATEMENTS PRIOR TO SIGNING THIS APPLICATION:
All of the information provided on this application is accurate. Failure to report accurate information is considered FRAUD. This includes failing to report all persons living in the household, failing to report all income, from all sources, failing to report all bank accounts, making false statements and withholding information. Failure to comply with program requirements could result in repayment of any benefits you receive and/or being ineligible for additional assistance. I understand that all payments will be made directly to the vendor or landlord. Coalition of Powhatan Churches staff are the only persons permitted to authorize payments made by the program. Furthermore, it is my responsibility to provide all required documents to the agency. This includes the legal name of a company, an accurate address and account numbers. Failure to provide documents will result in this application being denied. Completion of this application gives the agency permission to verify sources of income and balances in bank accounts. Approval of funds is contingent upon meeting the Coalition of Powhatan Churches' guidelines and the availability of funds. I fully understand the above statements. ***By stating your name this is an electronic signature****

Print Name: (Electronic signature) *

Date: *

ACKNOWLEDGEMENT FORM
With the submission of this application, you acknowledge that your application information will be placed in Empowor, which is a shared database by the following agencies:
1. The Coalition of Churches
2. Free Clinic of Powhatan
3. Habitat for Humanity
4. Community Life Church
5. Powhatan Community Action Agency
6. Powhatan YMCA
7. The Willow Collaborative
Your information could be shared between any of the above-mentioned organizations from the date of application.

Signature (Electronic) *

Date *

Income: (Verification required for all income received within the past 60 days)
Type/Source & Household, Member *

Gross Amount/Frequency *

Type/Source & Houshold, Member *

Gross Amount/Frequency *

TOTAL Household Income: *

Submit

We accept checks made out to "Coalition of Powhatan Churches". Please mail them to: PO Box 57, Powhatan VA 23139

We accept donations via Paypal!