FINANCIAL ASSISTANCEConnecting community needs with effective resources. This form is used as a screening tool. It does not guarantee assistance. Additional information will be obtained to determine eligibility.*Please give UWBC up to 48 hours to properly respond*Applicants who qualify can only be assisted one time per year through the United Way Assistance Fund.*Please give UWBC up to 48 hours to respond**Please give UWBC up to 48 hours to respond*Verification* Do you acknowledge that you already called 2-1-1 for resources?Date* MM slash DD slash YYYY Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email* Home/Personal Cell Phone*Alternate PhoneType of Assistance Requested*Total Number of people in household*12345678910Total Household Monthly Income: $*Source of Income* Job SSI SSD State Assistance SSType of State Assistance (if applicable): Food Assistance (BridgeCard) Cash Assistance (FIP) Healthcare Day Care State Emergency Relief (SER)List other agencies you have asked for assistanceAre you or anyone in your household a Veteran?*YesNoAre you at risk for homelessness?*YesNoConsent* YesDo you give permission to the United Way of Bay County (Michigan) to use your information in this application to contact relevant agencies? All information provided is only used to determine eligibility of your request and is kept confidential. If you need any assistance with this application or have any general questions about financial assistance, please contact MaryBeth at 989-893-7508 or [email protected].
