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APPLICATION FOR ASSISTANCE

We are here to help, please fill out this form and we will be in touch with you.

I am giving my permission for SHOC to access information regarding me/my family from other Human Service Organizations to assist in best determining my eligibility. SHOC is only assisting me to apply for SHOC program benefits.

Please tell us how you found our agency. Who referred you to SHOC? If it was an agency were they able to assist you?

Phone were you can be reached

Please fill out your full address: house/apt # and street, city state and zipcode


If you are a renter, repairs are the responsibility of your landlord. If you are looking for assistance with rent/security deposit, you must have found a property to rent. **Landlord name, address, phone is required.

Please list all children name & age

Are you employed ?
Yes
No

IF you are not Employed answer 0

Do you receive Unemployment ?
Yes
No
Do you receive a Pension payment?
Yes
No
Do you receive a Social Security payment?
Yes
No
Do you receive Food Stamps?
Yes
No
Do you receive Child Support ?
Yes
No
Do you receive HEAP assistance ?
Yes
No
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