515-296-1449 gneainc@gmail.com

Rent / Utility Form

Applicant Information

last four digits

Household Information

Other Assistance

Example
Story County Community Services
   • 2018-11-01 – Granted. Received rent assistance.
Mid-Iowa Community Action (MICA)
   • 2018-12-01 – Denied. Did not receive utilities assistance.
Salvation Army
   • 2018-12-10 – Granted. Received clothing.
Emergency Residence Project (ERP)
   • 2018-12-15 – Granted. Received utilities assistance.
City of Ames
   • 2018-12-18 – Granted. Received food vouchers ($300).
Religious Organizations
   • 2018-12-29 – Cornerstone Church. Received $250 for groceries.

Additional Information

Rent Assistance

Complete this section only if you need rent assistance.

If your request for assistance is approved, payment will be made directly to your housing provider.

Utilities Assistance

Complete this section only if you need utilities assistance.