**TO RECEIVE A COVID-19 FOOD BOX PLEASE COMPLETE THE APPLICATION BELOW** ELIGIBILITY CRITERIA: Must be 18 years of age or older Ouachita Region Resident Unemployed/loss of income due to COVID-19 Household Information Head of Household Last Name Head of Household First Name Other Adults Mailing Address Address1 Address2 City State - Select -Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip Code Contact Information Contact's Email Cell Phone Number Other Phone Number County of Residence Name of Current / Most Recent Employer Date unemployed due to COVID-19 Employer Phone Number Family Type - Select -Single Person Single Parent- Female Single Parent - Male Two Adults - No Children Two Parent Household Total Number in Household Individuals by Category Please indicate the number of individuals in your household in each age category below (enter a 0 if there are none in that age group): Ages 0 to 5 Ages 6 to 12 Ages 13 to 17 Ages 18 to 59 Ages 60+ I Need Assistance With: Rent/Mortgage Electric Bill Gas Bill Water Bill Sewage/Trash Bill Fuel/Oil Food Gas/Public Transportation Prescriptions/Medical Other Rent/Mortgage Info Rent/Mortgage Amount Upload Copy of Current/ Past Due Rental or Mortgage Agreement Upload Upload requirementsOne file only.200 MB limit.Allowed types: jpg, jpeg, png, gif, pdf, doc, docx, xls, xlsx. Electric Bill Info Electric Bill Amount Upload Copy of Current/ Past Due Electric Bill Upload Upload requirementsOne file only.200 MB limit.Allowed types: jpg, jpeg, png, gif, pdf, doc, docx, xls, xlsx. Gas Bill Info Gas Bill Amount Upload Copy of Current/ Past Due Gas Bill Upload Upload requirementsOne file only.200 MB limit.Allowed types: jpg, jpeg, png, gif, pdf, doc, docx, xls, xlsx. Water Bill Info Water Bill Amount Upload Copy of Current/ Past Due Water Bill Upload Upload requirementsOne file only.200 MB limit.Allowed types: jpg, jpeg, png, gif, pdf, doc, docx, xls, xlsx. Sewage/Trash Bill Info Sewage/Trash Bill Amount Upload Copy of Current/ Past Due Sewage/Trash Bill Upload Upload requirementsOne file only.200 MB limit.Allowed types: jpg, jpeg, png, gif, pdf, doc, docx, xls, xlsx. Fuel/Oil Info Fuel/Oil Amount Upload Supporting Documents for Fuel/ Oil Assistance Upload Upload requirementsOne file only.200 MB limit.Allowed types: jpg, jpeg, png, gif, pdf, doc, docx, xls, xlsx. Gas/Public Transportation Info Gas/Public Transportation Amount Upload Supporting Documents for Gas/ Public Transportation Assistance Upload Upload requirementsOne file only.200 MB limit.Allowed types: jpg, jpeg, png, gif, pdf, doc, docx, xls, xlsx. Prescriptions/Medical Info Prescriptions/Medical Amount Upload Supporting Documents for Prescription/Medical Assistance Upload Upload requirementsOne file only.200 MB limit.Allowed types: jpg, jpeg, png, gif, pdf, doc, docx, xls, xlsx. Explain 'Other' Note: These funds are NOT to be used to purchase alcohol, nicotine, or any illegal substances. Proofs Prior to receiving assistance, you must first submit a copy of your valid driver’s license, or ID, as well as either proof of application/determination letter for unemployment compensation or letter from employer. Upload a Copy of your Driver's License or Other Proof of Identification Upload Upload requirementsOne file only.200 MB limit.Allowed types: jpg, jpeg, png, gif, pdf, doc, docx, xls, xlsx. Proof of Application / Unemployment or Letter from Employer Upload Upload requirementsOne file only.200 MB limit.Allowed types: jpg, jpeg, png, gif, pdf, doc, docx, xls, xlsx. Affirmation I understand that this information is utilized to determine eligibility for the COVID-19 Relief Fund for which I am applying. I hereby certify to the best of my knowledge, the information contained herein is true, and correct. My signature also gives permission for United Way of the Ouachitas to sign the Charity Tracker release form on my behalf. Charity Tracker is a cloud-based network which records assistance and tracks the monies provided to residents in the Ouachita region. Your Signature Reset CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit
