Rent & Utility Assistance Form
*Please review the most recent notes about assistance (what we have current funding for) before you fill-out this online form. It may take 3-5 business days to receive a reply. We are working through requests as quickly as possible. We apologize that the threat of the Coronavirus has made an online form a necessity, since we would rather meet with you in person to help you in your time of crisis.* With Love & Prayers, The Majors Thies
Email *
First Name *
Last Name *
Date Of Birth *
Please enter your legal date of birth!
MM
/
DD
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YYYY
Please enter the last four digits of your Social Security Number. (This is used for inter-agency reporting and verification of previous assistance)
What is your current need? *
Many clients have multiple needs, but please just select or enter the most urgent need and reason for your form submission.
What is the total amount you currently owe? (Please include any overdue payments, late charges, etc.)
If you are requesting assistance with a utility or water bill, please provide your account number. If you are requesting assistance with rent, please provide your landlord's name and phone number. Failure to provide this information will slow down the processing of your request.
Why are you in need of help today? *
Please provide details of WHY you are in need, not what you need.
Have you sought help with this need elsewhere? *
Please list the organization/institution/person where you have sought assistance, WHEN you sought assistance, and the result of your request.
(For example: I sought assistance for household items from Operation Threshold yesterday the 16th of March, but they didn't have what I needed.) If you answered NO above, then please skip this question.
Have you received the requested assistance from The Salvation Army before? *
If you answered YES to the above question, when and what type of assistance did you receive?
Phone Number With Area Code *
If the above phone is not your personal phone, what is the name of the intermediary contact?
What is your preferred method of follow-up contact? *
As of today, what are your three most significant other needs?
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