UCHM Emergency Assistance Request
UCHM provides support for individuals and families in our community who find themselves in emergency situations. Funding is provided in part by our local churches, individual donations and by Louisville Metro Community Services & Revitalization. Emergency Assistance is supported by Dare to Care, Louisville Metro Office of Resilience and Community Services, local businesses, UCHM’s 21 member churches, and individual supporters.

United Crescent Hill Ministries’ Emergency Assistance programs serves the needs of those living in the 40206 zip code. If you require another neighborhood ministry that might be of service to you, please visit the member listing page of Louisville’s Association of Community Ministries here. If you live in the 40206 zip code and would like to request financial assistance, please complete the UCHM Emergency Assistance Request Form below.
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First Name *
Last Name *
Address *
Zip Code *
Date of Birth *
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List the last four digits of your social security number. *
Phone Number *
E-mail
Have you are anyone in your family received services for rent or utilities from the community ministries? If so please please list year and service. *
Total Number in Household *
Household Member Names and Date of Birth *
Monthly Household Income (Gross) *
Monthly Household Income (Before COVID-19)
Current Monthly Household Income Source
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Please indicate which service(s) you are requesting: *
Required
What crisis has occurred in your life that causes you to not be able to afford to pay this bill yourself. PLEASE BE SPECIFIC. (ie. COVID-19, childbirth, loss of job, car repairs, death in family, medical bills). If crisis is due to COVID-19, please indicate specifically. *
5. If you need utility assistance, is your service currently connected?
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If you are requesting assistance with utilities, please list account number(s).
If your LG&E is still on, what is the brown bill date? OR If your water is on, what is the cutoff date? (Required)
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If bill is in someone else's name, please list name.
If you are requesting rental assistance, what is the name of your landlord/rental company/mortgage company?
Landlord Phone and E-mail
If you are requesting rental assistance, how much do you owe and for what month(s) are you requesting assistance?
9. 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. *SLCM RepresentativeSelf (Applicant)Nonprofit EmployeeFriend or Family Member of Applicant *
NOT REQUIRED: What is your ethnicity? (We collect this information for grant reporting purposes, it is not required)
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NOT REQUIRED: Gender
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Other Comments or Questions:
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