Services of Hope 2021 Winter Emergency Grant Application
RequiredRequired Question(s)
Personal information is never shared with anyone outside of our organization. 
The more information you provide, the faster we can process your application.
 
Required 1.

Name (Nombre)

 

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Required 2.

Address (Direccion)

 

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Required 3.

City (Ciudad)

 

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Required 4.

State (Estado)

 

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Required 5.

Zip Code

 

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Required 6.
Phone Number (Número de Teléfono)
 

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Required 7.

Email (Correo Electrónico)

 

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Required 8.

Confirm Email Address

 

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Required 9.

Have you previously received assistance from this Winter Storm Grant?

If so, please indicated what funds were used for.

*Receiving funds does not disqualify you from receiving assistance again.

Yes
No
  • Comment:

  • 500 characters left.
Required 10.

Female Head of Household? (¿CABEZA DE FAMILIA SOLO?)

Yes
No
Required 11.

Number of People in Household? (Numero en el Hogar)

 

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Required 12.

What is Your Income Range? (¿Cuál es tu rango de ingresos?)

$.00-$10,000
$10,001-30,000
$30,001-50,000
$50,001 +
Required 13.
Ethnicity (pertenencia étnica)
White / Blanco
Black / Africano
Asian / Asiático
American Indian / Natural de Alaska
Pacific Islander / Isleño Pacífico
Other/Multi-Racial
Hispanic
Required 14.

Were you affected by the winter storm that occurred Sunday, February 14-Thursday, February 17th?

Yes
No
Required 15.

Do you rent or own your home?

Rent
Own
Required 16.
What issues occurred in your household as a result of the recent winter storm? Select all that apply
No Heat
Busted Pipes/Plumbing Issues/Flooding
Loss of Food
Temporary Housing Costs
Vehicle Damage
Unable to work
Contaminated Water
Structural Damage
Furniture Damage
Loss of Medication (i.e. refrigerated medication)
Other  
Required 17.

What type of assistance are you seeking due to being affected by the recent winter storm? (You will be required to provide proof of cost, receipts, landlord information, account numbers, login information, etc.)

Food
Hotel Cost /Reimbursement
Mortgage Assistance
Transportation Expenses
Utility Assistance
Medication Costs
Clean Water
Home Repairs
Plumber Expenses
Furniture Replacement
Other  
Payment Information 
*If you are applying for Utilities or other Services-Funds will be paid directly to the company. 
*If you need RENTAL ASSISTANCE, please refer to the resource page that we will take you to once you have submitted this application.
 
18.

Landlord Information 

*Please include all information to speed up application process

1. Name of Complex (if applicable)

2. Contact Person

3. Address

4. Phone Number

5. How you pay (Money Order, Online, Cash, etc.)

6. Login Information

7. Amount you cannot pay

 

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19.
Utility Assistance
*Please include all information to speed up application process
1. Utility Type (i.e. water, electricity, gas)
2. Name of Company
3. Company Phone Number
4. Account Number
5. How you pay (Online, Over Phone, Mail In)
6. Login Information
7. Amount you cannot pay
 

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20.

Food Assistance

1. Number of Children in home?

2. Number of adults in home?

3. Virtual Learning?

 

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21.

Temporary Housing caused by the recent winter storm

*You will be required to provide receipt

1. Name of Motel

2. Address

3. Phone Number

4. Nightly Amount

5. Dates of stay

 

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22.

Household Repair Expenses caused by the recent winter storm (i.e. flooding, plumbing)

1. Name of Company

2. Phone Number

3. Quote Amount

 

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Required 23.

Have you filed an insurance claim for damages caused by the recent winter storm?

Yes
No
24.

Household Item Replacement (i.e. Furniture, Medication, Clothing)

1. List Damaged Items caused by the recent winter storm

 

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25.

Loss of Wages

1. How many hours of work did you miss because of the recent winter storm?

2. How much are you paid an hour?

 

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Required 26.

How did you hear about this program? If other, please specify.

Email
Social Media
Other  
Required 27.

Do you need a Spanish speaking representative to contact you?

Yes
No
PLEASE READ AND ACCEPT THE FOLLOWING STATEMENTS FROM SOH BEFORE SUBMITTING YOUR APPLICATION.

1. THE MORE INFORMATION YOU PROVIDE, THE FASTER WE CAN PROVIDE ASSISTANCE. 
2. ALL INFORMATION PROVIDED IS CONFIDENTIAL AND NEVER SHARED WITH AFFILIATES UNLESS NECESSARY FOR PAYMENT AND WITH YOUR PERMISSION.
3. COMPLETION OF THIS APPLICATION DOES NOT GUARANTEE ASSISTANCE.
4. YOU WILL BE CONTACTED BY A SOH REPRESENTATIVE TO DETERMINE ELIGIBILITY. WE WILL ONLY CALL ONCE. IF YOU MISS THE CALL, PLEASE CALL (214)519-8603 OR EMAIL WINTER@SERVICESOFHOPE.ORG. 
5. PLEASE GIVE US 14 DAYS TO PROCESS YOUR APPLICATION AND BEFORE CONTACTING US ABOUT YOUR APPLICATION.
 
Required 28.
I understand and agree to the above statements.

ACCEPT
DECLINE
Required 29.

Type your name below to electronically sign this application

 

50 characters left.