United Way Gift of Warmth Application
Pike County
Head of Household Name
*
First Name
Last Name
Social Security Number
*
Email
*
example@example.com
Spouse/ Partner Name
*
First Name
Last Name
Social Security Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What Township Do you Reside In?
Please Select
Blooming Grove
Delaware
Dingmans
Greene
Lackawaxen
Lehman
Milford
Palmyra
Porter
Shohola
Westfall
I do not know
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How many children under the age of 18?
*
Family Size
*
What is the Household Gross Annual Income?
*
Are you a Veteran?
*
Yes
No
Race, please check that apply.
*
American Indian/ Alaskan Native
Asian
Black/ African American
Native Hawaiian/ Pacific Islander
White
Ethnicity
*
Hispanic
Not Hispanic
Are you a homeowner or renter?
*
Homeowner
Renter
Who Referred you to our office?
*
Can You Please Tell the Reason Why you are Applying?
*
Expenses Increase Permanently
Expenses Increased One Time Unplanned
Family Problems
Job Loss
Job Pending
Hours Cut at Job
Medical Issues
Moving to New Location
Other
Please Provide us with a Brief Reason in Your words for this Application
*
Have you applied for LIHEAP?
*
Yes
No
INCOME
*
Rows
Amount
SOC. SECURITY
CHILD SUPPORT
ALIMONEY
PENSION
FOOD STAMPS
PENSION
TANF (CASH)
Total
UTILITY INFORMATION
*
UTILITY INFORMATION ACCOUNT NUMBER
*
LENDER INFORMATION
Document Upload
Please Upload the documents needed to complete your application
DRIVERS LICENSE/ ID CARD FOR ALL HOUSHOLD MEMBERS
*
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TAX RETURN
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WAGES/ PAYSTUBS FOR ALL HOUSEHOLD MEMBERS
*
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UE/ SSI
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Utility Bill
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LEASE (If you are a renter)
*
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MORTGAGE STATEMENT (If you are a homeowner)
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of
By submitting this application for assistance from the Pike County Human Services I hereby acknowledge and agree to the following terms and conditions: Accuracy of Information: I certify that all information provided in this application and in any attached documents is true, accurate, and complete to the best of my knowledge. I understand that any false statements or deliberate omissions may result in the denial of my application or termination of any assistance granted. Use of Information: I authorize Pike County Human Services and its agents to use the information provided in this application for the purpose of evaluating my eligibility for assistance. This may include verifying information with third parties, such as employers, landlords, and government agencies, as necessary. Privacy and Confidentiality: I acknowledge that Pike County Human Services is committed to maintaining the privacy and confidentiality of my personal information. Information provided in this application will be used solely for the purpose of assessing my need for assistance and will not be disclosed to any unauthorized parties without my explicit consent, except as required by law. No Guarantee of Assistance: I understand that submission of this application does not guarantee that I will receive assistance. Assistance is provided based on the availability of funds, the eligibility criteria of the program, and the demonstrated need of the applicants. Decisions made by Pike County Human Services regarding the distribution of assistance are final. Changes in Circumstances: Should my circumstances change after the submission of this application; I agree to notify Pike County Human Services promptly. This includes changes in income, family size, address, or any other information that could affect my eligibility for assistance. Terms and Conditions: I agree to comply with all terms and conditions of the assistance program, should I be selected to receive aid. I understand that failure to comply with program requirements may result in the termination of assistance. Release of Liability: I hereby release and hold harmless Pike County Human Services, its directors, officers, employees, and agents from any liability, loss, or damage arising from my participation in the Pike County Human Services or from the denial of my application. By signing below, I acknowledge that I have read, understand, and agree to the above terms and conditions. I also understand that this application is subject to review and approval by Pike County Human Services and that I may be asked to provide additional information or documentation as part of the review process.
*
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