Support EIU Employees
Application of need
Client Profile
Name *
Email *
Address *
Phone number *
Date of Birth *
If you have a disability indicate that type of disability (if you choose to disclose)
Are you pregnant, or parenting a child under the age of one? (optional)
Are youa Veteran? (optional)
Emergency Contact (Name. Relationship, and Phone)
Household Members
Type of Assistance Requested (Please indicate the assistance you are seeking)
Situation (optional)
Are you staying with a family member/Friend, or homeles shelter
Would you like information on Low income Housing, Food, or assistance with Health Care Resources?
Disconnection Notice
If you have received a disconnection notice please provide the utility provider, Account Number, Amount Past due, and Disconnection Date.
Eviction/Foreclosure Notice
If you have received a notice, please provide the type of notice, the amount past due, and the Eviction/Foreclosure Date.
Please report income and expenses as it will help determine your need
Sources of income for all members living in your household:Include income from employment, social security, food stamps, utility checks, public assistance, SSI/SSD, pensions, disability, unemployment, alimony, child support, VA benefits, family/friends assistance or other income.

Please provide individual, and income

household member 1
household member 2
household member 3
household member 4
household member 5
Monthly Expenses
Report actual amounts
Cell Phone
Car Payment
Property Tax
Actual Expenses spent monthly on additional items
Child Care
Car Fuel
Car Insurance
Other Insurance
Public Transportation
Paper Products
Personal Products
Baby Supplies
Other expenses
Assistance From Support EIU Employees
List all assistance received by Support EIU Employees in the last 12 months
Your application will be processed in the order received, and we will contact you by phone.
I understand that E.I.U. Employees behaves in a responsible manner with my information, and will not be held liable if the online services is compromised because the provider of said online services is at fault. Support E.I.U. Employees takes your privacy very seriously. Once the application is fulfilled it will no longer be accessible online by anyone. *
* By submitting this application, I allow Support E.I.U. Employees to process my request for service. The information provided in this application is true and accurate to the best of my knowledge. I also understand that Support E.I.U. Employees may contact utility and other service providers to verify that all information is accurate and current. *
PLease send documentaion such as your unemployment letter to It will be added to your file, processed, then removed from any online activity.
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