Client Application

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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 application.

* = Required information

*Primary Language:
*First Name:
*Middle Name:
*Last Name:
*Gender:
*Date of birth: (MM/DD/YYYY format required)
*Ethnicity:
*County:
*City:
*Street:
*Zip Code:
*State:
*Country:
*Phone:
*Email:
*Homeless:
*Referral Source:
*Source of Income:
*Monthly Income:
*Are there other adults in household?
*Are there children in household?
*Service Requested:
*Reason for Need:
*Need for Help Detail:
*Employer Company Name:
*Employer Contact Person:
*Employer Phone:
*Do we have permission to contact your Employer?
Current Amount Owed (for rent and utility assistance applications):
Apartment Name (for rent assistance applications):
Do we have permission to contact your Landlord (for rent assistance applications)?
Payee Name (landlord, utility company or repair shop):
Payee Phone (landlord, utility company or repair shop):
Past Due Amount (for rent and utility assistance applications):
West Cap Contacted? (required for utility assistance applications between Oct and May):
Utility Acct # (for utility assistance applications):
Do we have permission to contact your Utility Company (for utility assistance applications)?
Years at Address (for rent assistance applications):
Client Contribution (amount you are able to pay toward rent, utility or repair costs):
Shut Off Date (for utility assistance applications):