COVID-19 Application

ELIGIBILITY CRITERIA:

  • Must be 18 years of age or older
  • Ouachita Region Resident
  • Unemployed/loss of income due to COVID-19
 
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Note: The most recent version of Chrome is not working with our file remove or upload buttons. We are working on this. A work-around is to:  1) Use a different browser if possible, or 2) Change how you upload. In the file upload field, select the file you want to upload but don't click the uploaded button. Just click the submit button at the bottom of the page. The file will upload when the page saves, you just won't see the upload progress.

Household Information
Please list the Name(s) of all other adults living in your Household (18 and older). Separate the names with commas.
Mailing Address
Contact Information
Individuals by Category
Please indicate the number of individuals in your household in each age category below (enter a 0 if there are none in that age group):
In your explanation, include the monetary amount of the assistance you are requesting.
Rent/Mortgage Info
$
Files must be less than 25 MB.
Allowed file types: gif jpg jpeg png pdf.
Electric Bill Info
$
Files must be less than 25 MB.
Allowed file types: gif jpg jpeg png pdf.
Gas Bill Info
$
Files must be less than 25 MB.
Allowed file types: jpg jpeg pdf ppt.
Water Bill Info
$
Files must be less than 25 MB.
Allowed file types: jpg jpeg pdf.
Sewage/Trash Bill Info
$
Files must be less than 25 MB.
Allowed file types: jpg jpeg pdf.
Fuel/Oil Info
Files must be less than 25 MB.
Allowed file types: jpg jpeg pdf.
Gas/Public Transportation Info
$
Files must be less than 25 MB.
Allowed file types: jpg jpeg pdf.
Prescriptions/Medical Info
$
Files must be less than 25 MB.
Allowed file types: jpg jpeg pdf.

Note: These funds are NOT to be used to purchase alcohol, nicotine, or any illegal substances.

Proofs
Prior to receiving assistance, you must first submit a copy of your valid driver’s license, or ID, as well as either proof of application/determination letter for unemployment compensation or letter from employer.
Files must be less than 25 MB.
Allowed file types: jpg jpeg pdf.
Files must be less than 25 MB.
Allowed file types: jpg jpeg pdf.

I understand that this information is utilized to determine eligibility for the COVID-19 Relief Fund for which I am applying. I hereby certify to the best of my knowledge, the information contained herein is true, and correct. My signature also gives permission for United Way of the Ouachitas to sign the Charity Tracker release form on my behalf. Charity Tracker is a cloud-based network which records assistance and tracks the monies provided to residents in the Ouachita region.