Financial Assistance Request Form

Voluntary Action Center
Financial Assistance Request Form
 

Our organization provides financial assistance to prevent eviction and loss of utility services.  We do not have funding to pay deposits or to establish utility service. 

YOU MUST BE A RESIDENT OF GORDON COUNTY TO RECEIVE ASSISTANCE.

YOUR BILL MUST BE DUE WITHIN 5 DAYS OR CURRENTLY PAST DUE. 

THE NAME ON THE BILL OR LEASE MUST BE THE NAME ON THE APPLICATION AND MATCH THE ID ATTACHED.

COMPLETION OF THIS FORM DOES NOT AUTOMATICALLY APPROVE YOUR REQUEST.  A CASE MANAGER WILL CONTACT YOU TO DISCUSS YOUR REQUEST AND LET YOU KNOW AT THAT TIME IF YOUR REQUEST IS APPROVED.  MORE DOCUMENTATION MAY BE REQUIRED.

IF YOU DO NOT ATTACH ALL REQUIRED DOCUMENTS OR ATTACHMENTS ARE NOT COMPLETE YOUR APPLICATION WILL BE CONSIDERED INCOMPLETE AND YOUR APPLICATION WILL BE DENIED.

Financial Assistance Application

The following questions must be answered to complete the application.  Information must be provided for all individuals currently residing in the household.  Anyone not listed on this application will not be allowed into the program.


Have you received your 2019 tax refund? *
Have you received stimulus money? *

Household Sources of Income

Do you currently work? *
Have you applied for disability? *
Do you draw disability or Social Security? *
If you're currently unemployed, are you applying for employment? *
Does anyone other than you draw disability or social security? *

Budget Worksheet

TOTAL MONTHLY INCOME 
List income for all individuals currently living in the home.  If someone gives you cash that is considered income.  You will be required to provide proof of income for at least one adult in the household.  Proof of income consists of paystubs, W2, tax returns, social security or disability benefits letters, TANF, child support, cash payments, separation notices, or letter where someone else pays your bills.

Do you receive food stamps? *
Total Monthly Income:
0.00
TOTAL MONTHLY EXPENSES 
List all monthly expenses you are currently paying.
Total Monthly Expenses:
0.00

What Type of Financial Assistance Are You Requesting?

Please select the type of assistance you are requesting: *
If you selected utility, is your service pre-pay? *
Are you needing assistance due to Covid-19? *

Request Verification

By Signing Below you agree that all information provided is accurate. *
clear
 +