Application for COVID-19 Assistance Please allow 3-5 business days to process your request. Before starting the application, please gather the following documentation that you will need to scan and upload into this form: Your photo ID Social Security cards for all members of your household The bill with which you need assistance (utility or rent statement) Proof that your need is COVID-related, including positive test results, layoff notice, unemployment documentation, etc. Proof of income for the past 30 days, including pay stubs, SNAP benefits, child support, TANF, disability, unemployment, etc. If someone else pays your bills, you must provide a statement of how long they have been paying your bills and the amount they provide. If you are unemployed, you must provide proof that you have been seeking employment, have applied for disability, or explain the reason you cannot work. Your employment, residency, income, and other information will be verified by the caseworkers processing your application. All information must be correct and up-to-date.Eligibility for AssistancePlease check all that apply to determine your eligibility:* I was employed prior to the COVID-19 outbreak and was laid off or had my hours significantly reduced. I contracted COVID-19 or am the caretaker of someone who did. I am at high risk for COVID-19 due to a pre-existing medical condition and am unable to work, or I am the caretaker of someone at high risk. I am 65 or older. None of the above apply to me. Which county do you live in?* Chickasaw Itawamba Lee Monroe Pontotoc Prentiss Tishomingo Union None of the above Type of Assistance Requested* Utilities Rent Personal InformationPlease answer these questions for yourself or the person requesting the assistance.Name* First Last Spouse/Partner Name, if applicable First Last Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone*Spouse/Partner Phone, if applicableEmail Date of Birth* MM slash DD slash YYYY Age*Gender*MaleFemaleOther/Prefer not to sayRace or EthnicityAsian/Pacific IslandAfrican-American/BlackCaucasian/WhiteHispanic/LatinoNative AmericanMore than one raceOther/Prefer not to sayMarital Status*SingleMarriedLiving with PartnerSeparated/DivorcedWidowedOtherHighest Education Level*Less than high schoolHigh School DiplomaSome college, no degreeAssociate's DegreeBachelor's DegreeMaster's or Professional DegreeDoctorateAre you a veteran or a member of the armed forces?*I have never served in the armed forces.Currently serving in the armed forcesVeteranHousehold InformationHow many adults reside in your household?*12345 or moreHow many children under the age of 18 reside in your household?*0/none123456 or moreAre you currently employed?* Yes No Current or Former Employer* Current or Former Employer's Phone Number*What is your total annual household income from all sources?*What is the source(s) of your household income?* Does anyone in your household receive any of the following?*Please check all that apply. TANF (Temporary Aid for Needy Families, aka cash assistance) SNAP (Supplemental Nutrition Assistance Program, aka food stamps) DHS Daycare Assistance None of the above. Does anyone in your household have the following types of health insurance?*Please check all that apply. Medicaid CHIP Medicare Employer-Provided Insurance Private Insurance None of the above. DocumentationPlease provide a copy of your photo ID.* Drop files here or Select files Max. file size: 8 MB. Please provide Social Security cards for all members of your household.* Drop files here or Select files Max. file size: 8 MB. Please provide a copy of the bill for which you are requesting assistance.* Drop files here or Select files Max. file size: 8 MB. Please provide proof that your need is COVID-related.*Examples are: postive COVID test results, layoff notice, paystubs showing reduced hours, unemployment, and any other documents that support your need for COVID-related assistance. Drop files here or Select files Max. file size: 8 MB. Please provide proof of all household income for the past 30 days.* Drop files here or Select files Max. file size: 8 MB. If you are unemployed, please provide proof of job search, application for disability, or the reason you cannot work. Drop files here or Select files Max. file size: 8 MB. ConfirmationConsent and Confirmation*I certify that all information provided in this application is true and complete to the best of my knowledge. Checking this box serves as my electronic signature and consent to use this information to determine my eligibility for assistance. I agree.Check if form was filled out on location CHANGE Amory (St. Helen's Catholic Church) First Baptist Amory Form filled out by
