RIVER CENTER LIFE ASSISTANCE REQUEST (v1.7.21)

We are only accepting applications from New Castle, Silt, and Apple Tree Park currently.

If you live outside of those areas please refer to www.a2pcovid.org for organizations serving your area.

Incomplete forms are subject to denial. All information is confidential and will only be used for purposes of considering your application for financial assistance.

YOU WILL NOT RECEIVE AN IMMEDIATE ANSWER ON YOUR REQUEST. PLEASE ALLOW UP TO 48 BUSINESS HOURS FOR US TO GET BACK TO YOU ON YOUR APPLICATION.


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Email *
Date of application: *
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Referred by: *
Referral contact #: We will reach out to verify referral. *
Applicant Full Name: *
DOB: *
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Ethnicity: *For grant reporting purposes only. Does not affect decision on assistance. *
Primary Language: *
Physical Address: *
City: *
If other, list city.
How long have you been at this residence? *
Home Phone # *
Mobile # *
Spouse/Partner Mobile #
Spouse/Partner's Email:
Do you own or rent? *
Do you have a roommate? *
If yes, how much does the roommate pay per month?
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