Individual COVID-19 funding request | United Way of Lincoln County

Applicant Contact Information

First Name

Last Name

Home Street Address:

City:

State:

Zipcode:

Phone w/area code:

Email:

Spouse First and Last Name:

Children - First Names Only - If none, enter NA:

Emergency Contact:

Describe the need and how it will be utilized (i.e., car payment, rent, mortgage, utilities, etc) to improve a degraded quality of life or prevent destitution:

Amount requested from UWLC: $

Number of people working in the household:

Total Yearly Income: $

Total Yearly Expenses: $

Rent or Own Home?

Rent

Own

Have you applied for the following:

Unemployment

Yes

If yes, when?

SB Loans

Yes

If yes, when?

Payroll Protection

Yes

If yes, when?

Have you reached out to other county agencies for help?

Yes

If yes, which agencies?

Payment is provided directly to the service provider(s) and is a one-time payment.

1. Service Provider Name:

Phone Number:

Mailing Address

City, State, Zip Code:

Date Payment Due:

Account Number:

2. Service Provider Name:

Phone Number:

Mailing Address

City, State, Zip Code:

Date Payment Due:

Account Number:

3. Service Provider Name:

Phone Number:

Mailing Address

City, State, Zip Code:

Date Payment Due:

Account Number:

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Signature

In order for your application to be processed, ALL information provided will be verified. By signing below, I authorize United Way of Lincoln County to contact any individuals/companies listed on my application for verification of information submitted.