Emergency Financial Assistance

Client Application

This application is for Rent, Utilities, or Car Repair requests only. Please submit only one application per instance of need.

Allow up to 3 business days for our Case Manager to respond after submitting your application.

Incomplete applications cannot be processed.

* = Required information

Personal information

* Primary Language

* First Name

* Middle Name

* Last Name

* Gender

* Date of Birth

MM/DD/YYYY format required

* Ethnicity

Contact information

* Phone

* Email

* Street Address

* City

* State

* Zip Code

* County

* Country

Household information

* Homeless

* Other adults in household?

* Children in household?

* Referral Source

Financial information

* Source of Income

* Monthly Income

Employer information

* Employer Company Name

* Employer Contact Person

* Employer Phone

* Permission to contact employer?

Service requested

* Service Requested

* Reason for Need

* Need for Help Detail

Client Contribution

Amount you are able to pay toward rent, utility, or repair costs

Rent assistance details

Complete this section for rent assistance applications only.

Apartment Name

Permission to contact landlord?

Current Amount Owed

Past Due Amount

Payee Name

Landlord, utility company, or repair shop

Payee Phone

Landlord, utility company, or repair shop

Years at Address

Utility assistance details

Complete this section for utility assistance applications only.

Utility Account Number

Permission to contact utility company?

Shut Off Date

West Cap Contacted?

Required for utility assistance applications between October and May

Client Application

Fresh Harvest Pantry hours

Resource Center Hours

Stay connected

Programs

Quick links

Contact