United Against Hunger - Storm Response Grant | United Way of Washington County, MD

First Name of Applicant

Last Name of Applicant

Applicant Street Address

City

State

Zip Code

Best phone number to contact you:

Applicant Email Address

Applicant Date of Birth

Gender of Applicant

Gender Pronoun

What race best describes you?

What best describes your ethnicity?

Number of Individuals Residing at this Address

Number of Individuals with Income at this Address

Are you or someone in the household a person with a disability?

Please list everyone who lives with you, their age, and relationship:

Are you or anyone in the household a veteran?

Annual Household Income (Must provide proof):

Income Sources (select all that apply):

Alimony

Child Support

Employment

Investment Income

Pension

Rental Income

Veteran's Benefits

Other

Please list all employer(s) and their address(es):

What describes your housing/living situation?

What assistance are you seeking today?

Are you receiving services from any community organization?

If yes, what organizations?

Is anyone in the household receiving assistance/benefits (Section 8, SNAP, etc.)?

If yes, please list:

Have you or a member of your household experienced any of the following major life events because of this disaster?

Additional information:

I agree to the terms of service.

By checking this box, you are agreeing to our terms of service.
You understand and certify that:

You have answered all questions truthfully.
You have submitted all documents requested and that they are accurate.
You understand that United Way of Washington County, Maryland (“Agency”) utilizes a data management tool to collect information. This allows for information to be entered once, reducing the number of times a client must continue to provide personal information. Collected information includes, but is not limited to first name, last name, date of birth, race, ethnicity, income, benefits, disabilities, and other identifying information. This information will be used to help access and obtain the most appropriate services. The Agency has an interagency sharing agreement with the collaborating agency or agencies regarding clients that are served by such agencies. All participating agencies have an agreement regarding security protocol on protection and sharing of client data. United Way of Washington County may also use your non-identified information for reporting requirements
No information will be released without signed client consent or by a court-ordered warrant.The client has the right to have their information removed, and may refuse to answer any question, unless entry into a program requires it.
Information that is transferred over the web is done through a secure and encrypted connection.
United Way of Washington County may use the internet or email to inform clients of available services.
United Way of Washington County and its community partners protect client information and only use information for case management services and service planning.
Unted Way of Washington County will uphold Federal and State confidentiality regulations to records and privacy.
United Way of Washington County will not solicit or input information from clients unless essential to meet minimum data requirements, provide services, or conduct evaluations or research.
United Way of Washington County may not use any client personal information for marketing purposes.
You have the right to request information about who has viewed or updated your file.
You have a right to receive a copy of this Consent Form.

By consenting to this agreement, you authorize the United Way of Washington County, Maryland:

To share your intake information with collaborating agencies to be used for referrals and coordination of services.
To provide basic demographic information, residential, employment/income, military, and service needs.
To allow your information to be shared electronically via a secure, encrypted, web-based system to the collaborating agencies.
To allow your records and information to be shared for a period of no greater than three years (3) from today’s date.

**Please submit all required documentation so that we may process your application**

Proof of address may be a utility bill, bank statement, rental/lease agreement, letter from the IRS or other government agency, etc.
Income verification may be pay stubs, W-2 forms, most recent tax return, Social Security benefits, etc.

Upload your verification of address

Upload requirements

Upload you proof of income

Upload requirements

Additional proof of income

Upload requirements

Signature (This verifies the above information is true and accurate)