Citrus UW

United Way of Citrus County Logo

REQUIREMENTS TO APPLY FOR ASSISTANCE

IN ORDER TO BE CONSIDERED FOR ASSISTANCE, YOU MUST BE A CITRUS COUNTY RESIDENT, MUST BE ABLE TO PROVIDE REQUESTED DOCUMENTATION (CASE BY CASE BASIS) AND MUST BE ABLE TO COME TO YOUR APPOINTMENT AT OUR UNITED WAY OFFICE. APPOINTMENTS WILL BE SCHEDULED UPON SUBMISSION OF THIS FORM.

CONTACT INFORMATION

FIRST NAME

LAST NAME

BEST CONTACT NUMBER

SPOUSE/SIGNIFICANT OTHER FULL NAME (IF APPLICABLE)

STREET ADDRESS

City

State

Zip

NUMBER & AGES OF CHILDREN (IF APPLICABLE)

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DESCRIBE YOUR NEED FOR ASSISTANCE (INCLUDE $ AMOUNT)

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WHAT EVENTS LED YOU TO NEEDING ASSISTANCE? (BE SPECIFIC)

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HOW DID YOU HEAR ABOUT US?

HAVE YOU RECEIVED ASSISTANCE FROM UNITED WAY BEFORE?

IF YES, PROVIDE APPROXIMATE DATE AND EXPLANATION OF LAST ASSISTANCE RECEIVED

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ARE YOU CURRENTLY EMPLOYED?

IF YES, PROVIDE NAME AND PHONE NUMBER OF EMPLOYER

LIST ALL CURRENT SOURCES OF INCOME (CHILD SUPPORT, FOOD STAMPS, DISABILITY ETC)

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REQUIREMENTS TO APPLY FOR ASSISTANCE

CONTACT INFORMATION

FORM SUBMISSION