CSBG Assistance Application
Please note that all required documents may be uploaded by taking a picture with your phone. Please be sure that the document can be read clearly.
Date*
Month Day Year
Is this COVID-19 Related?
Yes No
Head of Household*
First Name Last Name
State ID Number*
Upload photo of State ID
Browse Files
Please be sure that numbers are readable. Cancelof
Head of Household Birthdate*
Month Day Year
Head of Household Gender*
Male Female
Head of Household Phone Number
Area Code Phone Number
Head of Household Email
example@example.com
Head of Household Education*
Choose the option that best represents you.
Head of Household Disabled?*
Yes No
Head of Household Race*
Choose the option that best represents you.
Head of Household Ethnicity*
NOT Hispanic or Latino Hispanic or Latino
Head of Household Employment*
Choose the option that best represents you.
Head of Household Health Insurance*
Choose the option that best represents you.
Head of Household Veteran?*
Yes No
How Many in Household?*
1 2 3 4 5 6 7 8 9 10
Family Type*
Choose the option that best represents you.
Housing*
Choose the option that best represents you.
Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
I am requesting assistance for the following:*
Rental Assistance Utility Assistance
2nd Member of Household
Name
First Name Last Name
Relationship to Head of Household
Choose the option that best represents you.
Birthdate
Month Day Year
Is this person over 18?
Yes No
Gender
Male Female
Education
Choose the option that best represents you.
Disabled?
Yes No
Race
Choose the option that best represents you.
Ethnicity
NOT Hispanic or Latino Hispanic or Latino
Employment
Choose the option that best represents you.
Health Insurance
Choose the option that best represents you.
Veteran?
Yes No
3rd Member of Household
Name
First Name Last Name
Relationship to Head of Household
Choose the option that best represents you.
Birthdate
Month Day Year
Is this person over 18?
Yes No
Gender
Male Female
Education
Choose the option that best represents you.
Disabled?
Yes No
Race
Choose the option that best represents you.
Ethnicity
NOT Hispanic or Latino Hispanic or Latino
Employment
Choose the option that best represents you.
Health Insurance
Choose the option that best represents you.
Veteran?
Yes No
4th Member of Household
Name
First Name Last Name
Relationship to Head of Household
Choose the option that best represents you.
Birthdate
Month Day Year
Is this person over 18?
Yes No
Gender
Male Female
Education
Choose the option that best represents you.
Disabled?
Yes No
Race
Choose the option that best represents you.
Ethnicity
NOT Hispanic or Latino Hispanic or Latino
Employment
Choose the option that best represents you.
Health Insurance
Choose the option that best represents you.
Veteran?
Yes No
5th Member of Household
Name
First Name Last Name
Relationship to Head of Household
Choose the option that best represents you.
Birthdate
Month Day Year
Is this person over 18?
Yes No
Gender
Male Female
Education
Choose the option that best represents you.
Disabled?
Yes No
Race
Choose the option that best represents you.
Ethnicity
NOT Hispanic or Latino Hispanic or Latino
Employment
Choose the option that best represents you.
Health Insurance
Choose the option that best represents you.
Veteran?
Yes No
6th Member of Household
Name
First Name Last Name
Relationship to Head of Household
Choose the option that best represents you.
Birthdate
Month Day Year
Is this person over 18?
Yes No
Gender
Male Female
Education
Choose the option that best represents you.
Disabled?
Yes No
Race
Choose the option that best represents you.
Ethnicity
NOT Hispanic or Latino Hispanic or Latino
Employment
Choose the option that best represents you.
Health Insurance
Choose the option that best represents you.
Veteran?
Yes No
7th Member of Household
Name
First Name Last Name
Relationship to Head of Household
Choose the option that best represents you.
Birthdate
Month Day Year
Is this person over 18?
Yes No
Gender
Male Female
Education
Choose the option that best represents you.
Disabled?
Yes No
Race
Choose the option that best represents you.
Ethnicity
NOT Hispanic or Latino Hispanic or Latino
Employment
Choose the option that best represents you.
Health Insurance
Choose the option that best represents you.
Veteran?
Yes No
8th Member of Household
Name
First Name Last Name
Relationship to Head of Household
Choose the option that best represents you.
Birthdate
Month Day Year
Is this person over 18?
Yes No
Gender
Male Female
Education
Choose the option that best represents you.
Disabled?
Yes No
Race
Choose the option that best represents you.
Ethnicity
NOT Hispanic or Latino Hispanic or Latino
Employment
Choose the option that best represents you.
Health Insurance
Choose the option that best represents you.
Veteran?
Yes No
9th Member of Household
Name
First Name Last Name
Relationship to Head of Household
Choose the option that best represents you.
Birthdate
Month Day Year
Is this person over 18?
Yes No
Gender
Male Female
Education
Choose the option that best represents you.
Disabled?
Yes No
Race
Choose the option that best represents you.
Ethnicity
NOT Hispanic or Latino Hispanic or Latino
Employment
Choose the option that best represents you.
Health Insurance
Choose the option that best represents you.
Veteran?
Yes No
10th Member of Household
Name
First Name Last Name
Relationship to Head of Household
Choose the option that best represents you.
Birthdate
Month Day Year
Is this person over 18?
Yes No
Gender
Male Female
Education
Choose the option that best represents you.
Disabled?
Yes No
Race
Choose the option that best represents you.
Ethnicity
NOT Hispanic or Latino Hispanic or Latino
Employment
Choose the option that best represents you.
Health Insurance
Choose the option that best represents you.
Veteran?
Yes No
Head of Household Income Information
I have Income to Report*
Yes No
Income Total by Employment
Enter Zero if No Income
Pay Period
Enter Monthly if No Income
Income Total by Benefits
Enter Zero if No Benefits received.
Choose Types of Benefits Received
Affordable Care Act Subsidy Childcare Voucher Housing Choice Voucher HUD-VASH LIEAP Permanent Supportive Housing Public Housing SNAP WIC None
Other Income Total
Enter Zero if No Other Income received.
Choose Types of Other Income Received
Alimony or other Spousal Support Child Support Housing Choice Voucher EITC Interest Pension Private Disability Insurance Retirement Income From Social Security SSDI (Social Security Disability Income) SSI (Supplemental Security Income) TANF Unemployment Insurance VA Non-Service Connected Disability VA Service Connected Disability Workers Compensation
Income Document Upload
Browse Files
Cancelof
2nd Member Income Information
I have Income to Report
Yes No
Income Total by Employment
Enter Zero if No Income
Pay Period
Enter Monthly if No Income
Income Total by Benefits
Enter Zero if No Benefits received.
Choose Types of Benefits Received
Affordable Care Act Subsidy Childcare Voucher Housing Choice Voucher HUD-VASH LIEAP Permanent Supportive Housing Public Housing SNAP WIC None
Other Income Total
Enter Zero if No Other Income received.
Choose Types of Other Income Received
Alimony or other Spousal Support Child Support Housing Choice Voucher EITC Interest Pension Private Disability Insurance Retirement Income From Social Security SSDI (Social Security Disability Income) SSI (Supplemental Security Income) TANF Unemployment Insurance VA Non-Service Connected Disability VA Service Connected Disability Workers Compensation
Income Document Upload
Browse Files
Cancelof
3rd Member Income Information
I have Income to Report
Yes No
Income Total by Employment
Enter Zero if No Income
Pay Period
Enter Monthly if No Income
Income Total by Benefits
Enter Zero if No Benefits received.
Choose Types of Benefits Received
Affordable Care Act Subsidy Childcare Voucher Housing Choice Voucher HUD-VASH LIEAP Permanent Supportive Housing Public Housing SNAP WIC None
Other Income Total
Enter Zero if No Other Income received.
Choose Types of Other Income Received
Alimony or other Spousal Support Child Support Housing Choice Voucher EITC Interest Pension Private Disability Insurance Retirement Income From Social Security SSDI (Social Security Disability Income) SSI (Supplemental Security Income) TANF Unemployment Insurance VA Non-Service Connected Disability VA Service Connected Disability Workers Compensation
Income Document Upload
Browse Files
Cancelof
4th Member Income Information
I have Income to Report
Yes No
Income Total by Employment
Enter Zero if No Income
Pay Period
Enter Monthly if No Income
Income Total by Benefits
Enter Zero if No Benefits received.
Choose Types of Benefits Received
Affordable Care Act Subsidy Childcare Voucher Housing Choice Voucher HUD-VASH LIEAP Permanent Supportive Housing Public Housing SNAP WIC None
Other Income Total
Enter Zero if No Other Income received.
Choose Types of Other Income Received
Alimony or other Spousal Support Child Support Housing Choice Voucher EITC Interest Pension Private Disability Insurance Retirement Income From Social Security SSDI (Social Security Disability Income) SSI (Supplemental Security Income) TANF Unemployment Insurance VA Non-Service Connected Disability VA Service Connected Disability Workers Compensation
Income Document Upload
Browse Files
Cancelof
5th Member Income Information
I have Income to Report
Yes No
Income Total by Employment
Enter Zero if No Income
Pay Period
Enter Monthly if No Income
Income Total by Benefits
Enter Zero if No Benefits received.
Choose Types of Benefits Received
Affordable Care Act Subsidy Childcare Voucher Housing Choice Voucher HUD-VASH LIEAP Permanent Supportive Housing Public Housing SNAP WIC None
Other Income Total
Enter Zero if No Other Income received.
Choose Types of Other Income Received
Alimony or other Spousal Support Child Support Housing Choice Voucher EITC Interest Pension Private Disability Insurance Retirement Income From Social Security SSDI (Social Security Disability Income) SSI (Supplemental Security Income) TANF Unemployment Insurance VA Non-Service Connected Disability VA Service Connected Disability Workers Compensation
Income Document Upload
Browse Files
Cancelof
6th Member Income Information
I have Income to Report
Yes No
Income Total by Employment
Enter Zero if No Income
Pay Period
Enter Monthly if No Income
Income Total by Benefits
Enter Zero if No Benefits received.
Choose Types of Benefits Received
Affordable Care Act Subsidy Childcare Voucher Housing Choice Voucher HUD-VASH LIEAP Permanent Supportive Housing Public Housing SNAP WIC None
Other Income Total
Enter Zero if No Other Income received.
Choose Types of Other Income Received
Alimony or other Spousal Support Child Support Housing Choice Voucher EITC Interest Pension Private Disability Insurance Retirement Income From Social Security SSDI (Social Security Disability Income) SSI (Supplemental Security Income) TANF Unemployment Insurance VA Non-Service Connected Disability VA Service Connected Disability Workers Compensation
Income Document Upload
Browse Files
Cancelof
7th Member Income Information
I have Income to Report
Yes No
Income Total by Employment
Enter Zero if No Income
Pay Period
Enter Monthly if No Income
Income Total by Benefits
Enter Zero if No Benefits received.
Choose Types of Benefits Received
Affordable Care Act Subsidy Childcare Voucher Housing Choice Voucher HUD-VASH LIEAP Permanent Supportive Housing Public Housing SNAP WIC None
Other Income Total
Enter Zero if No Other Income received.
Choose Types of Other Income Received
Alimony or other Spousal Support Child Support Housing Choice Voucher EITC Interest Pension Private Disability Insurance Retirement Income From Social Security SSDI (Social Security Disability Income) SSI (Supplemental Security Income) TANF Unemployment Insurance VA Non-Service Connected Disability VA Service Connected Disability Workers Compensation
Income Document Upload
Browse Files
Cancelof
8th Member Income Information
I have Income to Report
Yes No
Income Total by Employment
Enter Zero if No Income
Pay Period
Enter Monthly if No Income
Income Total by Benefits
Enter Zero if No Benefits received.
Choose Types of Benefits Received
Affordable Care Act Subsidy Childcare Voucher Housing Choice Voucher HUD-VASH LIEAP Permanent Supportive Housing Public Housing SNAP WIC None
Other Income Total
Enter Zero if No Other Income received.
Choose Types of Other Income Received
Alimony or other Spousal Support Child Support Housing Choice Voucher EITC Interest Pension Private Disability Insurance Retirement Income From Social Security SSDI (Social Security Disability Income) SSI (Supplemental Security Income) TANF Unemployment Insurance VA Non-Service Connected Disability VA Service Connected Disability Workers Compensation
Income Document Upload
Browse Files
Cancelof
9th Member Income Information
I have Income to Report
Yes No
Income Total by Employment
Enter Zero if No Income
Pay Period
Enter Monthly if No Income
Income Total by Benefits
Enter Zero if No Benefits received.
Choose Types of Benefits Received
Affordable Care Act Subsidy Childcare Voucher Housing Choice Voucher HUD-VASH LIEAP Permanent Supportive Housing Public Housing SNAP WIC None
Other Income Total
Enter Zero if No Other Income received.
Choose Types of Other Income Received
Alimony or other Spousal Support Child Support Housing Choice Voucher EITC Interest Pension Private Disability Insurance Retirement Income From Social Security SSDI (Social Security Disability Income) SSI (Supplemental Security Income) TANF Unemployment Insurance VA Non-Service Connected Disability VA Service Connected Disability Workers Compensation
Income Document Upload
Browse Files
Cancelof
10th Member Income Information
I have Income to Report
Yes No
Income Total by Employment
Enter Zero if No Income
Pay Period
Enter Monthly if No Income
Income Total by Benefits
Enter Zero if No Benefits received.
Choose Types of Benefits Received
Affordable Care Act Subsidy Childcare Voucher Housing Choice Voucher HUD-VASH LIEAP Permanent Supportive Housing Public Housing SNAP WIC None
Other Income Total
Enter Zero if No Other Income received.
Choose Types of Other Income Received
Alimony or other Spousal Support Child Support Housing Choice Voucher EITC Interest Pension Private Disability Insurance Retirement Income From Social Security SSDI (Social Security Disability Income) SSI (Supplemental Security Income) TANF Unemployment Insurance VA Non-Service Connected Disability VA Service Connected Disability Workers Compensation
Income Document Upload
Browse Files
Cancelof
Assistance
Name of Person or Company to issue Check
Phone Number
Area Code Phone Number
Address to Mail Check
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Date Due
Month Day Year
Date
Regular Payment Amount
Amount Due
Amount you are able to contribute
Amount needed for Assistance
Upload Bill or other Documents
Browse Files
Please make sure that names and/or signatures are readable Cancelof
Signature Page
By signing this Application, I agree to allow Goshen HELP to share this application with The Salvation Army and/or Energy Share for the purpose of obtaining resources on my behalf.
Head of Household Signature*
Clear
Self Declaration for Head of Household
Self-Declaration for Zero Income or missing required documentation
(Only complete if you have no source of income or are missing any of the required documentation.)
I do hereby declare under penatly of purjury that I have received no income from any source during the past 30 days and that I have been unemployed during that time.
I have been able to maintain my basic necessities by doing the following:
Signature
Clear
Self Declaration for 2nd Household Member
Self-Declaration for Zero Income or missing required documentation
(Only complete if you have no source of income or are missing any of the required documentation.)
I do hereby declare under penatly of purjury that I have received no income from any source during the past 30 days and that I have been unemployed during that time.
I have been able to maintain my basic necessities by doing the following:
Signature
Clear
Self Declaration for 3rd Household Member
Self-Declaration for Zero Income or missing required documentation
(Only complete if you have no source of income or are missing any of the required documentation.)
I do hereby declare under penatly of purjury that I have received no income from any source during the past 30 days and that I have been unemployed during that time.
I have been able to maintain my basic necessities by doing the following:
Signature
Clear
Self Declaration for 4th Household Member
Self-Declaration for Zero Income or missing required documentation
(Only complete if you have no source of income or are missing any of the required documentation.)
I do hereby declare under penatly of purjery that I have received no income from any source during the past 30 days and that I have been unemployed during that time.
I have been able to maintain my basic necessities by doing the following:
Signature
Clear
Self Declaration for 5th Household Member
Self-Declaration for Zero Income or missing required documentation
(Only complete if you have no source of income or are missing any of the required documentation.)
I do hereby declare under penatly of purjery that I have received no income from any source during the past 30 days and that I have been unemployed during that time.
I have been able to maintain my basic necessities by doing the following:
Signature
Clear
Self Declaration for 6th Household Member
Self-Declaration for Zero Income or missing required documentation
(Only complete if you have no source of income or are missing any of the required documentation.)
I do hereby declare under penatly of purjery that I have received no income from any source during the past 30 days and that I have been unemployed during that time.
I have been able to maintain my basic necessities by doing the following:
Signature
Clear
Self Declaration for 7th Household Member
Self-Declaration for Zero Income or missing required documentation
(Only complete if you have no source of income or are missing any of the required documentation.)
I do hereby declare under penatly of purjery that I have received no income from any source during the past 30 days and that I have been unemployed during that time.
I have been able to maintain my basic necessities by doing the following:
Signature
Clear
Self Declaration for 8th Household Member
Self-Declaration for Zero Income or missing required documentation
(Only complete if you have no source of income or are missing any of the required documentation.)
I do hereby declare under penatly of purjery that I have received no income from any source during the past 30 days and that I have been unemployed during that time.
I have been able to maintain my basic necessities by doing the following:
Signature
Clear
Self Declaration for 9th Household Member
Self-Declaration for Zero Income or missing required documentation
(Only complete if you have no source of income or are missing any of the required documentation.)
I do hereby declare under penatly of purjery that I have received no income from any source during the past 30 days and that I have been unemployed during that time.
I have been able to maintain my basic necessities by doing the following:
Signature
Clear
Self Declaration for 10th Household Member
Self-Declaration for Zero Income or missing required documentation
(Only complete if you have no source of income or are missing any of the required documentation.)
I do hereby declare under penatly of purjery that I have received no income from any source during the past 30 days and that I have been unemployed during that time.
I have been able to maintain my basic necessities by doing the following:
Signature
Clear
How will this help?
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CSBG Assistance Application

2nd Member of Household

3rd Member of Household

4th Member of Household

5th Member of Household

6th Member of Household

7th Member of Household

8th Member of Household

9th Member of Household

10th Member of Household

Head of Household Income Information

2nd Member Income Information

3rd Member Income Information

4th Member Income Information

5th Member Income Information

6th Member Income Information

7th Member Income Information

8th Member Income Information

9th Member Income Information

10th Member Income Information

Assistance

Signature Page

Self Declaration for Head of Household

Self Declaration for 2nd Household Member

Self Declaration for 3rd Household Member

Self Declaration for 4th Household Member

Self Declaration for 5th Household Member

Self Declaration for 6th Household Member

Self Declaration for 7th Household Member

Self Declaration for 8th Household Member

Self Declaration for 9th Household Member

Self Declaration for 10th Household Member