Request for SWCM's Emergency Assistance
PLEASE NOTE THAT BY FILLING OUT THIS FORM, YOU ARE NOT GUARANTEED FINANCIAL ASSISTANCE. Unfortunately, due to limited funding and high volume of requests, less than half of requests can be processed. If we are able to schedule an appointment for assistance, we will contact you.

In the meantime, we encourage you to look for other resources and to request utility bill extensions and stay in communication with your landlord.

WE ONLY SERVE NEIGHBORS IN 40272, 40258, & the Jefferson County Portion of 40177. Please only fill out this form if you live in one of these zip codes.

Copy and past this URL for a map: shorturl.at/flAC6
Input your address and zoom out to see if it falls in Southwest Community Ministries area.

Your information below will be kept confidential! Please fill this form out as completely as possible. We can better help you if we know your story, goals, and challenges.
Full Name *
Address *
Zip Code - We Can ONLY serve neighbors who live in 40272, 40258, & the Jefferson County Portion of 40177. If you live in another zip code please go back to our Need Help Page - to find a listing of ALL community ministries by zip code and how to apply for assistance. *
Date of Birth
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Last 4 of Social
Phone Number(s) *
By Checking Yes, you agree to the following: The information on this Southwest Community Ministries Request for Financial Assistance form has been furnished by me. I authorize SWCM to release this information and any additional information updating what is on this form, if requested to other financial assistance agencies and churches. I understand that I have the right to amend, correct, or delete any of this information at any time. I also give SWCM and any and all other organizations working with them permission to contact Louisville Gas & electric company, the Louisville Water Company, and / or any rental or mortgage persons or institutions to access information on my account as required for financial assistance. I also give further permission for SWCM to give basic statistic to Louisville Jefferson County Metro Government for future funding. I understand that my refusal to "sign" this release will result in my being denied any financial assistance by SWCM. *
Required
Additional Phone Number and Name of Contact (Friend or Family Member who Can Reach you)
Email
Do you have a way to email/fax/text documentation to us? (i.e. take photos of your bill, have landlord fax us your lease, etc?)
Clear selection
Have you or a family member living in your house been to SWCM before for anything?
Clear selection
If yes, what other name might we have on file?
Total Number Living in Household
Total Number of Seniors in Household (+60)
Have you applied for or do you receive Food Stamps
Clear selection
If you receive food stamps, what is your monthly food stamp income?
Have you had a loss of income or any crisis in your life in the last 2 months?
What is your utility bill account number(s)
If the bill is in someone else's name, what is their name?
If you need help with rent, who is your landlord?
If you have received an eviction notice or letter threatening eviction?
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Will your landlord take partial payment?
Clear selection
Who is filling out this form? If you are filling this form out on behalf of the applicant, please leave your information in the comment section below. *
Other questions/comments/concerts: Please let us know anything else about your situation that you think we should know or any questions that you have.
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