United Christian Ministries: Financial Assistance Request Form

If you are seeking ONLY food assistance, you do NOT need to fill out this form. We have implemented a drive-thru system, so you don't have to get out of your vehicle. We are open on Mondays, Wednesdays and Fridays from 9-noon. Please bring your ID.

Email address *

A UCM representative will be contacting you as soon as possible to conduct an intake interview over the phone. Our normal procedures would require you to come in for a face-to-face intake but, due to COVID-19, we are modifying our procedures.

What is your FIRST name as it appears on your ID? *

Your answer

What is your LAST name as it appears on your ID? *

Your answer

Please provide a phone number where you can be reached during the day. *

Your answer

Have you received food or financial assistance from United Christian Ministries before? *

Yes

I'm not sure or I don't remember

Required

How can we help you? What kind of financial assistance are you requesting help with today? *

Utility assistance

Fuel assistance

Rent assistance

Other

Required

We often need to contact other agencies in order to determine the approval or denial of your request for financial assistance. This may include your utility company, landlord, employer or other local agencies that you have recently received financial assistance from. (Check only one box.) *

I hearby authorize United Christian Ministries (UCM) to request and/or release any and all information concerning my employment, financial affairs, applications for assistance, family & personal relationships, and such other information as may be needed to determine the approval or denial of my request to UCM for assistance. Futhermore, I certify the information given to a UCM representative to be true. I understand that if such information is found to be false, I forfeit the right to receive assistance from UCM both now and in the future.

I do not authorize United Christian Ministries to request and/or release my information in order to determine the approval or denial of my request for assistance. I understand that I may not be able to receive financial assistance from UCM without this approval. (Please call 864-671-1134 and leave a message if you have questions or concerns about this procedure. A UCM representative will return your call as soon as possible.)

Required

As stated above, a UCM representative will be contacting you as soon as possible. Below are the topics that will be discussed during the intake process. Please check each box after you have read the descriptions so that you will be prepared to answer related questions during the intake. *

HOUSEHOLD PROFILE (names of everyone in the home, their dates of birth, genders, relationships to you, education levels, social security numbers)

MONTHLY INCOME (employer name or type of income for everyone in the home, $ per hour and hours per week working on average, gross monthly income, SNAP benefit amount)

MONTHLY EXPENSE AMOUNTS (rent or mortgage, phone, electricity, water, heat, transportation, medical, loans, credit cards, child care, tobacco, Internet, cable, etc.)

Required

Before any financial commitments can be made, we will need the following documents from you. You can either email a copy or picture of them to ucmpc2018@gmail.com or fax them to 864-671-1135. During the intake process, we can discuss further and answer any questions you have. Please check all the boxes below after you have read each requirement. *

ID (If your ID does not include your current address, we will also need proof of residency.)

Social Security cards for everyone in the home (If we already have copies in your file, you do not need to resubmit them.)

Proof of earned income for everyone in the home (pay check stubs for the last 30 days or 2019 income tax return)

Proof of unearned income (If we have your 2020 Social Security award letter on file, you do not need to resubmit it.)

An eviction or late notice if seeking rent assistance

A copy of your current utility bill if seeking utility assistance

Required

Send me a copy of my responses.

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