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Client Application OLD

Client Application

This application is for Rent, Utilities or Car Repair requests only.
Please allow up to 3 business days for our Case Manager to respond after submitting application.

Client Intake

Please select your primary language *

(Select to view all options)

Por favor, haga clic en el botón rojo "Español" si lo prefiere.

First Name *

Middle *

Last *

Gender

Gender Other

Date of Birth *

Age *

Race *

This information is needed for funding and grants so that we may provide this service.

Race Other

Phone *

Email

Homeless

Check here if homeless

Address *

Address Line 2

Apt #

City *

State *

ZIP Code *

How did you hear about us?

Hear about us other

Approximate Household Gross Monthly Income (before taxes) *

Source of Income *

Fuente de ingreso *

Income source other

Employer Information

Employer Name *

Contact Name

Employer Phone *

We require permission to contact your employer *

I agree

Employer Information

Employer Name *

Contact Name

Employer Phone *

We require permission to contact your employer *

I agree

What caused you to need help? *

Limit 300 characters

Are there other adults in your household? *

Yes

No

Other Adults in Your Household

Other Adult First Name *

Other Adult Last Name *

Gender

Gender Other

Age *

Race *

Race Other

Relationship to Client *

Are there children in your household? *

Yes

No

Children in Your Household

Child First Name *

Child Last Name *

Gender

Gender Other

Age *

Race *

Race Other

Relationship to Client *

What financial assistance is needed? (Check all that apply) *

Rent

Utilities

Car Repair

¿Qué asistencia financiera se necesita? (Marque todo lo que corresponda) *

Alquilar

Utilidades

Reparación de autos

Rent Assistance

How much rent is owed?

Rent Past Due *

Current Rent *

Landlord Name *

Landlord Phone *

Apartment Name

We require permission to contact your landlord *

I agree

Rent Assistance

How much rent is owed?

Rent Past Due *

Current Rent *

Landlord Name *

Landlord Phone *

Apartment Name

We require permission to contact your landlord *

I agree

Utility Assistance

How much is the bill?

Utilities Past Due *

Current Utilities *

Utility Company Name *

Utility Company Phone *

Utility Account Number *

This is required for the case manager.

We require permission to contact your utility company *

I agree

From October 1st – May 15th, you must call WestCap at 715-265-4271 to apply for utility assistance before our Case Manager calls you.

Utility Assistance

How much is the bill?

Utilities Past Due *

Current Utilities *

Utility Company Name *

Utility Company Phone *

Utility Account Number *

This is required for the case manager.

We require permission to contact your utility company *

I agree

From October 1st – May 15th, you must call WestCap at 715-265-4271 to apply for utility assistance before our Case Manager calls you.

Car Repair Assistance

Do you have an car repair estimate? *

Yes

No

An estimate is required when the case manager calls you. If "No" is selected, a link to a list of approved shops will be displayed.

Estimate Amount *

Repair Shop Name *

Repair Shop Phone *

An estimate is required for assistance. Click here to see a list of approved car repair shops.

Car Repair Assistance

Do you have an car repair estimate? *

Yes

No

An estimate is required when the case manager calls you. If "No" is selected, a link to a list of approved shops will be displayed.

Estimate Amount *

Repair Shop Name *

Repair Shop Phone *

Se requiere una estimación. Haga clic aquí para ver una lista de talleres de reparación de automóviles aprobados.

If you are human, leave this field blank.

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Operation HELP is a 501(c)(3) organization.

Operation HELP is a United Way funded organization

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