United to Help Our Neighbors Screening Questions

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please answer the following questions to see if you qualify for United to Help Our Neighbors funding.

Important:
--This is a SCREENING QUESTIONNAIRE to see if your family qualifies for funding.

--After submitting this form, CHECK YOUR EMAIL AND SPAM FOLDERS for a reply from the United Way.

--If you qualify for funding, you should receive an email within 72 hours with detailed instructions.

--Due to the high volume of applicants, individuals who do not qualify will not receive an email.

--Do not call the United Way to follow up on your screening questionnaire.

State your First and Last Name.
*

Provide a contact phone number. You will ONLY be contacted if your appear to qualify for funding *

Provide your email address. You will be contacted by email if you qualify for this grant. *

Are you the head of the household whose name appears on your lease/mortgage, utility bills, and/or childcare documents/bills?
*

Yes, I am the head of the household whose name appears on a lease/mortgage and/or utility bills and/or childcare bills.

No--If your answer is "No," please have the qualifying head of the household fill out the screening questionnaire. To qualify, you will need to supply documents that prove you are on a lease/mortgage, utility bills, etc.

Do you rent a home/apartment in Missouri, own a home in Missouri, or reside in Missouri?
*

Yes

No--Unfortunately, if your answer is "No," you do not qualify.

Other:

Which county do you live in?
*

Howell

Oregon

If you do not live in one of the above counties, you will not qualify for funding with the Heart of the Ozarks United Way. Go to www.211helps.org/uhons/ to see which United Way covers your county.

Do you reside in a household with a child aged UNDER 18?
*

Yes

No--Unfortunately, if your answer is "No," you do not qualify.

State the total number of individuals, including children, in your household.

State the combined gross monthly income of all members in the household. Gross income is pre-tax and pre-deductions. The monthly income must be the total of all incomes in the household, including wages, SNAP, SSI, Social Security, or other incomes.

For those who need rental assistance...
*

Rent is already past due.

Rent is not past due.

Other:

For those who need utility assistance...
*

My utility account is already past due.

My utilitiy account is not past due.

Other:

For those who need car repairs...
*

My car is used to get to work.

My car is used to get to job interviews.

My car is not used to get to work or get to interviews.

My car does not need repairs.

For those who need support paying for childcare...
*

I am employed.

I am seeking employment.

I am not employed or seeking employment.

I do not need childcare support.

If there is clarifying information you'd like to add for any of the questions, briefly state it here. And please remember to check your email for a reply from the United Way if you qualify. If you do not qualify, you will not receive an email.

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms