http://cm2aum.neworg.com/compformdisplay.asp?pagenum=59&formnum=15&cn=&can=&sid=384515355
Client Application
 
Application for Emergency Financial Assistance
****Arlington Residents Only****
Please Fill in this form COMPLETELY.

When completing the Assistance Application through the Portal, please be sure to use Google Chrome Mozilla Firefox or Microsoft Edge  . Using these browsers will ensure a successful application submission as Microsoft no longer provides security updates or technical support for older versions on Internet Explorer. Without security updates, user systems become vulnerable to malware. 

 

Personal Information



Enter your name as shown on I.D.
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Employment History



* Required

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Household Income



Please list ALL sources of Income. Please note you will be required to provide additional information for other household members.
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(Amount Housing pays: rent + utility allowance)

Monthly Expenses


Household Information


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What bill do you require assistance paying?
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Crisis Information


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CONSENT FOR RELEASE OF INFORMATION:

I understand that in order to determine my eligibility for assistance, I must complete an intake assessment with an Arlington Urban Ministries case manager. I agree to provide the information necessary to make a decision regarding my request for service. I certify that the information is true and correct, to the best of my knowledge. ALL of this information will be recorded in Arlington Urban Ministries? electronic database. I also understand that providing the information DOES NOT guarantee that I will receive assistance from Arlington Urban Ministries.

I also authorize the securing of information from other agencies and the release of information in my case record to any other agency or entity as may be needed to determine the outcome of my request for assistance. This sharing of information includes the retrieval of information from and or the sharing of information with any community client management system databases which the Arlington Urban Ministries utilizes.

I have read and understand the Arlington Urban Ministries Consent for Release of Information form. I give my consent.

* Required