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Application
Personal Information
First Name
*
*
Middle Name
*
Last Name
*
*
SSN
*
*
Date of Birth
*
*
Phone Number
*
*
Email
*
*
*
Street
*
*
City
*
*
Zip Code
*
*
County
*
Adams
Asotin
Benton
Chelan
Clallam
Clark
Columbia
Cowlitz
Douglas
Ferry
Franklin
Garfield
Grant
Grays Harbor
Island
Jefferson
King
Kitsap
Kittitas
Klickitat
Lewis
Lincoln
Mason
Okanogan
Pacific
Pend Oreille
Pierce
San Juan
Skagit
Skamania
Snohomish
Spokane
Stevens
Thurston
Wahkiakum
Walla Walla
Whatcom
Whitman
Yakima
Military Service
Date of Entry
*
*
Date of Discharge
*
*
Type of Discharge
*
Honorable
General (Under Honorable Conditions)
Bad Conduct
Dishonorable
Other Than Honorable
Uncharacterized
Unknown
Branch of Service
*
Army
Air Force
Navy
Marine Corps
Coast Guard
National Guard
Air Guard
Army Reserves
Navy Reserves
USAF Reserves
USN Reserves
USMC Reserves
CG Reserves
VA Benefits & Entitlements Status
Claim Filed for VA Disability (SC Compensation)
*
Claim Filed for VA Disability (SC Compensation)
No
Claim Filed for VA Disability (SC Compensation)
Yes
Claim Date for VA Disability (SC Compensation)
*
Current Combined Rating (%)
0
10
20
30
40
50
60
70
80
90
100
Employment
Employment Status
*
Full-time Student looking for work
Full-time Student not looking for work
Part-time student looking for work
Part-time student not looking for work
Enrolled in apprenticeship program
Enrolled in OJT Program
Enrolled in Retraining Program
Enrolled in Job Retention Program
Full-time
Part-time
Day Labor
Unemployed - Seeking
Unemployed - In School - Not Seeking
Unemployed - Not In School - Not Seeking
Retired
Unable to Work (Disabled)
Retired & Disabled
I am applying for the following types of assistance:
Rent
Mortgage
Utilities
Other
*
Are you homeless?
Are you homeless?
No
Are you homeless?
Yes
If Yes, How Long? Years
*
*
*
If Yes, How Long? Months
*
*
*
Do you have an eviction notice?
Do you have an eviction notice?
No
Do you have an eviction notice?
Yes
Do you have a foreclosure notice?
Do you have a foreclosure notice?
No
Do you have a foreclosure notice?
Yes
Do you have a utility shut-off notice?
Do you have a utility shut-off notice?
No
Do you have a utility shut-off notice?
Yes
Declaration
I declare under penalty of perjury that the information I gave in this application is true, correct, and complete to the best of my knowledge. I understand that I can be criminally prosecuted if I incorrectly receive financial assistance because I have willfully made a false statement or willfully failed to report something I should report.
*
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