Citrus UW

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Contact information

First Name

Last Name

Mobile Number

Address

City

State

Zip

Are you a Citrus County Resident?

Name of employer

If unemployed at time of application, please check box and skip employment portion

Address of employer

Employer telephone number

Position/title at place of employment

Number of years at place of employment

Number of people residing in your household

Name, age and relationship to head of household for each individual residing in home

255 character limit

0 / 255

Are you in need of utility assistance?

Do you need rental/mortgage assistance?

Reason for need explained in detail (must be COVID-19 related).

255 character limit

0 / 255

CARES Documentation Requirements:

*Please use the checkbox below as a guide to ensure you are bringing all of the required documents. In order to receive assistance you will need to provide the following at time of appointment:

Driver's License or State ID for All Adults in Household

Birth Certificates for all children age 0-18 in household

Social Security Card for all household members or tax returns showing social security numbers

If needing utility assistance, copy of current bill

If needing rent/mortgage assistance, copy of lease and W-9 or mortgage statement

If needing rent or mortgage assistance, proof of PAST DUE balance

One of the Following:

Pre-pandemic and current bank statement, 2019 tax return and current paycheck stub, or Proof of financial hardship (i.e. letter from employer documenting loss of wages/income)

Upon form submission United Way will review your application and contact you to set up an appointment.

I hereby certify that the information given in this intake form is true and complete to the best of my knowledge. I understand that if I give inaccurate information, I may be liable for prosecution under state law.

I hereby grant United Way of Citrus County permission to contact other organizations for information and/or referral with respect to employment and receipt of benefits. All requests considered without regard to race, color, sex, age, or religious beliefs

I agree that by submitting, I am electronically signing this application

First and last name

Date