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.

Save & Return

Use an account to return to saved work.

Release of Information

Complete this first section about you, the person completing this application.

Complete this section for all individuals living in your home with you.
Individual #1
Individual #2
Individual #3
Individual #4
Individual #5
Individual #6

The Gordon County Community Services Network, hereinafter referred to as “GCCS Network”, is a shared, internet based record keeping system that records and stores information about emergency services provided, including but not limited to utility assistance, food, medication, rent/mortgage assistance, etc.  The Voluntary Action Center serves as the administration of the GCCS Network on behalf of Member Organizations.

I understand that all information gathered about me is private and that participation is voluntary.  I have had an opportunity to review this form and understand that the information collected regarding my assistance records is accessible by GCCS Network Members. 

This Release of information will remain in effect for three (3) years from the date noted by my signature at the bottom of this page unless I make a written request to this Organization to be removed from the GCCS Network.

I authorize the Voluntary Action Center, as a GCCS Network Member, to share my identifying information as well as assistance information, including denial of service within the GCCS Network.  I also authorize GCCS Network Members to make referrals to appropriate service providers, in an effort to implement service plans.  I understand that such service may include health, educational, psychological, nutritional, housing, financial, employment, and other services which may apply.  I understand that this information will be kept confidential by GCCS Network Members, unless required by law, as in situations such as child abuse or threats of harm to self and others.  In no instance, other in such required reports, will this information be provided to individuals or agencies that are not a part of this process.

I hereby authorize Voluntary Action Center to request information regarding education, income, medical, household composition, family services received, and psychological information as required to determine eligibility as well as services provided.  I understand that I must submit all information and forms requested by the Voluntary Action Center before my application will be considered for aid. 

I understand that by submitting an application for aid, I, and other members of my household, may have various assessments completed by the Voluntary Action Center staff, and agree to be an active participant in the implementation of the resulting service plans.  My signature below indicates my agreement for all individuals living in my home as listed on the back of this document, to participate in the process, as well.  It is my understanding that I may withdraw from participation at any time.

Release of Information Terms Agreement *
Client's Authorizing Signature: *
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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. *
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