ALICE SUPPORT FUND APPLICATION

Please note this form is used as a screening tool. It does not guarantee assistance. Additional information will be obtained to determine eligibility. Applicants who qualify can only be assisted one time per year. Questions? Please email ALICEsupport@uwgic.org or call (989) 773-9863.

Date

YYYY

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Age

Have you already called 2-1-1 for resources?

Yes

Are you a Veteran?

Total Number of People in Household

Total Household Monthly Income

Type of Assistance Requested

Rent

Utilities

Mortgage

FOR RENT

Provide your rent amount, landlord, and date due:

FOR UTILITIES

Provide your utility type/company, amount, and date due:

FOR MORTGAGE

Provide your mortgage amount, mortgage holder, and date due:

I certify that, to the best of my knowledge and belief, all the information presented and attached to this application is true, correct, and complete in every respect; fully discloses my household income from all sources; and accurately represents my/our current living circumstances.

ALICE SUPPORT FUND APPLICATION

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