COVID-19 Application

**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
Household Information
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): 

I Need Assistance With:
Rent/Mortgage Info
Upload requirements
Electric Bill Info
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Gas Bill Info
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Water Bill Info
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Sewage/Trash Bill Info
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Fuel/Oil Info
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Gas/Public Transportation Info
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Prescriptions/Medical Info
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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. 

Upload requirements
Upload requirements

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.