1Introduction2Information3Current Needs4Income5Expenses6Authorization7Signature Reminders: To receive the application link, you must be pre-qualified by United Way 211. The application link is non-transferable to other individuals. The timeline to process completed applications and submit electronic payments varies depending on the volume of applications being processed. Generally, it can take anywhere from 3-5 days for an application to be processed and for a decision to be made. It's important to provide all requested information and documentation promptly to avoid delays in processing. Before processing can begin, you must first complete financial counseling through Consumer Credit Counseling (CCCS). Once United Way receives your application and supporting documents, they will make a referral to CCCS for the required counseling. Before completing an application, please ensure you have all the required documentation listed below. Proof of Identity Government-issued ID: State Driver’s License, ID Card, U.S. Military ID Card, or Passport Proof of Residency in the City of Savannah/Chatham County Valid Government ID or Driver’s License Proof of 6 Months Residency Bank statements, pay stubs, or other acceptable documentation At-Risk of Displacement or Homelessness (Choose one): Eviction notice or dispossessory warrant Past due rent and/or utility notices Homelessness verification form Rental Unit Location within the City of Savannah Lease agreement signed by applicant and landlord including address and rent amount Proof of Household Income (All that apply) Unemployment compensation statement Paystubs or other wage statements Other benefit income: TANF, Social Security, child support, retirement, VA income, etc. Letter or attestation from employer Bank statements Applicant Name (Head of Household)(Required) First Last Date of Birth(Required)MM/DD/YYYY MM slash DD slash YYYY Street Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you currently homeless?(Required) Yes No Phone 1(Required)Phone 2Email(Required) Gender(Required) Male Female Transgender None of These Are you pregnant?(Required) Yes No Race(Required) Black or African American White American Indian or Alaskan Native Asian Native Hawaiian or Other Pacific Islander Some Other Race Ethnicity(Required) Hispanic or Latino Not Hispanic or Latino Living Status(Required) Single Married Widowed Separated Divorced Domestic Partner Common Law Highest Level of Education Completed(Required) Less than 9th grade 9th to 12th, no diploma High school diploma (includes equivalency) Some college or associate’s degree Bachelor’s degree Graduate or professional degree Military Status(Required) N/A Active Inactive Retired Medically Retired Discharged National Guard/Reserve Are you currently employed?(Required) Yes No Employer(Required)Are you employed?(Required) Full Time Part Time Unemployed Monthly household income(Required)Unemployment Status(Required)Check all that apply Actively Searching Not Actively Searching Re-Entering Pending Disability Physically Unable To Work Retired Active Parole or Probation(Required) Yes No Convicted Felon(Required) Yes No Registered Sex Offender(Required) Yes No Current needs(Required)To receive utility deposit assistance, you will need to provide a copy of your utility deposit statement. A dispossessory warrant or eviction notice is required for rental assistance, and a welcome letter from your property manager is necessary for rental security deposit assistance. Please ensure you have the appropriate documentation ready to proceed with your request for assistance. Utility Bills Rent/Mortgage Photo ID(Required)Accepted file types: jpg, pdf, png, Max. file size: 6 MB.Proof of residency(Required)Such as a piece of mail with your physical address on it.Accepted file types: jpg, pdf, png, Max. file size: 6 MB.Proof of income(Required)Such as a check stub, bank statement, or SS statement.Accepted file types: jpg, pdf, png, xls, xlsx, doc, Max. file size: 6 MB.Additional Proof of incomeSuch as a check stub, bank statement, or SS statement.Accepted file types: jpg, pdf, png, xls, xlsx, doc, Max. file size: 6 MB.Additional Proof of incomeSuch as a check stub, bank statement, or SS statement.Accepted file types: jpg, pdf, png, xls, xlsx, doc, Max. file size: 6 MB.Additional Proof of incomeSuch as a check stub, bank statement, or SS statement.Accepted file types: jpg, pdf, png, xls, xlsx, doc, Max. file size: 6 MB.Utility assistance documents(Required)Such as a past-due and/or disconnect notice.Accepted file types: jpg, pdf, png, Max. file size: 6 MB.Rent/mortgage assistance documents(Required)Such as a dispossessory warrant or eviction document. Accepted file types: jpg, pdf, png, Max. file size: 6 MB.Other Members of HouseholdMember 1 First Last Date of birthMM/DD/YYYY MM slash DD slash YYYY Gender Male Female RelationshipRace Black or African American White American Indian or Alaskan Native Asian Native Hawaiian or Other Pacific Islander Some Other Race Member 2 First Last Date of birthMM/DD/YYYY MM slash DD slash YYYY Gender Male Female RelationshipRace Black or African American White American Indian or Alaskan Native Asian Native Hawaiian or Other Pacific Islander Some Other Race Member 3 First Last Date of birthMM/DD/YYYY MM slash DD slash YYYY Gender Male Female RelationshipRace Black or African American White American Indian or Alaskan Native Asian Native Hawaiian or Other Pacific Islander Some Other Race Member 4 First Last Date of birthMM/DD/YYYY MM slash DD slash YYYY Gender Male Female RelationshipRace Black or African American White American Indian or Alaskan Native Asian Native Hawaiian or Other Pacific Islander Some Other Race Member 5 First Last Date of birthMM/DD/YYYY MM slash DD slash YYYY Gender Male Female RelationshipRace Black or African American White American Indian or Alaskan Native Asian Native Hawaiian or Other Pacific Islander Some Other Race Member 6 First Last Date of birthMM/DD/YYYY MM slash DD slash YYYY Gender Male Female RelationshipRace Black or African American White American Indian or Alaskan Native Asian Native Hawaiian or Other Pacific Islander Some Other Race Member 7 First Last Date of birthMM/DD/YYYY MM slash DD slash YYYY Gender Male Female RelationshipRace Black or African American White American Indian or Alaskan Native Asian Native Hawaiian or Other Pacific Islander Some Other Race Total members in household(Required)Public BenefitsWages(Required)Supplemental Security Income (SSI)(Required)Social Security Disability Insurance (SSDI)(Required)SSA(Required)Veterans Affairs Benefits (VA Benefits)(Required)Child Support(Required)Alimony(Required)Retirement(Required)Other Cash Support(Required)Medicaid(Required)Medicare(Required)Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)(Required)Other(Required)Total Income(Required) Monthly Household ExpensesHousing (Rent/Mortgage)(Required)Home Phone(Required)Cell Phone(Required)Internet/Cable(Required)Auto Payments(Required)Auto Repairs/Maintenance/Gas(Required)Medications(Required)Doctor Co-Pays(Required)Water Bill(Required)Electricity Bill/Gas Bill(Required)Food (Groceries)(Required)Insurances(Required)Loans(Required)Other(Required)Please Describe(Required)Other(Required)Please Describe(Required)Total Expenses(Required)TotalsTotal Section 1 Income(Required)Less Total Section 2 Expenses(Required)Budget Overage or Shortage(Required) Authorization and Consent to Release InformationPlease check next to each of the following statements indicating you have read (or someone has read to you) and understand each.Authorization(Required) I understand that completing this application does not guarantee assistance. Authorization(Required) I grant permission to United Way of the Coastal Empire (UWCE) to make use of the information herein regarding my household with other programs and agencies for the purpose of identifying the best possible assistance for my household. The information shared may include social security numbers, names and personal information, to include criminal background if necessary. Authorization(Required) I give permission for all state agencies to discuss this application with UWCE to determine application status. Authorization(Required) I understand that UWCE may use this information for research and reporting purposes. I further understand that UWCE will not share any personal information except as required by law. I certify that the information given in this application is true and accurate to the best of my knowledge. Authorization(Required) I agree to contact Consumer Credit Counseling Service. By signing my name below, I also certify that I have read this consent or that someone has read this to me. Please explain why you require assistance. Have you recently: lost your job, medical issues, etc.(Required)Name(Required) First Last Signature(Required)Date(Required)MM/DD/YYYY MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
