**TO RECEIVE A COVID-19 FOOD BOX PLEASE COMPLETE THE BELOW APPLICATION** ELIGIBILITY CRITERIA: Must be 18 years of age or older Ouachita Region Resident Unemployed/loss of income due to COVID-19 1 Start 2 Complete 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 Head of Household First Name * Head of Household Last Name * Other Adults Please list the Name(s) of all other adults living in your Household (18 and older). Separate the names with commas. Mailing Address Address1 * Address2 City * State * AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * Contact Information Contact's Email * Cell Phone Number * Other Phone Number County of Residence * Name of Current / Most Recent Employer * Date unemployed due to COVID-19 * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 Employer Phone Number * Family Type * - Select -Single PersonSingle Parent- FemaleSingle Parent - MaleTwo Adults - No ChildrenTwo Parent Household Total Number in Household * Individuals by CategoryPlease indicate the number of individuals in your household in each age category below (enter a 0 if there are none in that age group): Ages 0 to 5 * Ages 6 to 12 * Ages 13 to 17 * Ages 18 to 59 * Ages 60+ * I Need Assistance With * Rent/Mortgage Electric Bill Gas Bill Water Bill Sewage/Trash Bill Fuel/Oil Food Gas/Public Transportation Prescriptions/Medical Other Explain 'Other' In your explanation, include the monetary amount of the assistance you are requesting. Rent/Mortgage Info Rent/Mortgage Amount $ Upload Copy of Current/ Past Due Rental or Mortgage Agreement Files must be less than 25 MB.Allowed file types: gif jpg jpeg png pdf. Electric Bill Info Electric Bill Amount $ Upload Copy of Current/ Past Due Electric Bill Files must be less than 25 MB.Allowed file types: gif jpg jpeg png pdf. Gas Bill Info Gas Bill Amount $ Upload Copy of Current/ Past Due Gas Bill Files must be less than 25 MB.Allowed file types: jpg jpeg pdf ppt. Water Bill Info Water Bill Amount $ Upload Copy of Current/ Past Due Water Bill Files must be less than 25 MB.Allowed file types: jpg jpeg pdf. Sewage/Trash Bill Info Sewage/Trash Bill Amount $ Upload Copy of Current/ Past Due Sewage/Trash Bill Files must be less than 25 MB.Allowed file types: jpg jpeg pdf. Fuel/Oil Info Fuel/Oil Amount Upload Supporting Documents for Fuel/ Oil Assistance Files must be less than 25 MB.Allowed file types: jpg jpeg pdf. Gas/Public Transportation Info Gas/Public Transportation Amount $ Upload Supporting Documents for Gas/ Public Transportation Assistance Files must be less than 25 MB.Allowed file types: jpg jpeg pdf. Prescriptions/Medical Info Prescriptions/Medical Amount $ Upload Supporting Documents for Prescription/Medical Assistance 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. ProofsPrior 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. Upload a Copy of your Driver's License or Other Proof of Identification * Files must be less than 25 MB.Allowed file types: jpg jpeg pdf. Proof of Application / Unemployment or Letter from Employer * Files must be less than 25 MB.Allowed file types: jpg jpeg pdf. Affirmation * I so affirm 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.