I am a resident of Calloway County *

YES

NO

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

Need for the Budget Lab only

MM

DD

YYYY

Phone Number *

(###)

###

####

Marital Status *

Married

Single

Living with partner

Other

Are you eligible or have you signed up for the Child Tax Credit?

YES

NO

Employment Status *

Working full time

Working part time

Unemployed

Other

Have you applied for and receiving unemployment compensation? *

YES

NO

If yes to the above, what is the status of your application?

Waiting to hear

Application declined

Other

If you are unemployed, are you currently looking for work?

YES

NO

Do you need help looking for work?

YES

NO

Sources of income *

Employer working full time

Employer working part time

Social Security

Disability

Help from family and friends

SSI

Pension

Alimony/Child Support

Other

Have you requested assistance from any of these agencies; please check those that apply *

Need Line

Hope Calloway

West Kentucky Allied

Area churches

Calloway County Collective

Center for Accessible Living

Other

Have not applied

Have you applied for other assistance *

SNAP

SSI

KTAP

LIHEAP

Medical assistance

Have not applied

Are you currently 60+ days past due on rent or utilities? *

If you are not 60 days past due on rent or in danger of a utility disconnection your application will not be processed

YES

NO

If this is a request for utility assistance, which utility?

Murray Electric

Murray Municipal Utilities

West Kentucky Rural Electric

Other

Have you made arrangements for a payment plan with your utility company?:

YES

NO

Is this a request for rent assistance?

YES

NO

Have you received a court ordered eviction notice?

YES

NO

Have you applied for assistance from the United Way before? *

With the fund running low first time applicants will receive priority

YES

NO

When did you apply for assistance?

MM

DD

YYYY

Do you have a family budget? *

YES

NO

The United Way requires a free budget class to receive funds. Is this understood and agreed? *

Effective January 10, 2022

YES

NO