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Application For Assistance

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Assistance Requirements

Applicant must reside in Buckeye, Avondale, Goodyear, or Tolleson
Assistance is available up to $500
Assistance may be applied toward a past-due utility bill or past-due/late rent notice
A valid photo ID and copy of the past-due notice are required

All requests are subject to review, verification, eligibility requirements, and available funding.

Submitting an application does not guarantee approval or payment.

APPLICATION FOR ASSISTANCE

X/Twitter

This field is for validation purposes and should be left unchanged.

REQUESTED DETAILS

Cash Amount or Items Requested?(Required)

Purpose of Request?(Required)

What events lead to your needing assistance?(Required)

Have you received assistance from us in the past?(Required)

Yes

No

If yes, When/What for?(Required)

What steps have you taken to improve your situation?(Required)

Have you seen a financial counselor within the last six months?(Required)

No

Yes

If yes, with whom?(Required)

PERSONAL INFORMATION

First Name:(Required)

Last Name:(Required)

Address:(Required)

Street Address Address Line 2 City State ZIP Code

Email Address:(Required)

Cell Phone:(Required)

Work Phone:

Home Phone:

Gender:(Required)

Female

Male

Date of Birth:(Required)

Month

Day

Year

Age:(Required)

Marital Status:(Required)

LOCATION AND LIST EVERYONE CURRENTLY LIVING IN YOUR HOME

Address of Residence:(Required)

Street Address Address Line 2 City State ZIP Code

Do you Own/Purchasing or Renting?(Required)

Own/Puchasing

Renting

How long at present residence (Years)?(Required)

Do you have access to a car?(Required)

Yes

No

How many people are living in the home?(Required)

Please list everyone living in the home:

1st Person(Required)

Name:

Age:

Relationship:

2nd Person(Required)

Name:

Age:

Relationship:

3rd Person(Required)

Name:

Age:

Relationship:

4th Person(Required)

Name:

Age:

Relationship:

5th Person(Required)

Name:

Age:

Relationship:

6th Person(Required)

Name:

Age:

Relationship:

7th Person(Required)

Name:

Age:

Relationship:

8th Person(Required)

Name:

Age:

Relationship:

9th Person(Required)

Name:

Age:

Relationship:

10th Person(Required)

Name:

Age:

Relationship:

PRIMARY APPLICANT EMPLOYMENT HISTORY

Primary Applicant Name:(Required)

First Last

Present/Most Recent Employer:(Required)

How long were you emplyed? (Years)(Required)

Currently Working?(Required)

Yes

No

Supervisor:(Required)

Employer Phone:(Required)

Employers Address:(Required)

Street Address Address Line 2 City State ZIP Code

Position and Job Description:(Required)

Are you seeking employment?(Required)

Yes

No

Where are you currently seeking employment?(Required)

How long have you been unemployed? (Months)(Required)

What steps are you taking to seek active employment?(Required)

Reason for leaving last employer:(Required)

SPOUSE EMPLOYMENT HISTORY

Spouse Name:(Required)

First Last

Spouses Present/Most Recent Employer:(Required)

How long is/was the spouse emplyed? (Years)(Required)

Spouse Currently Working?(Required)

Yes

No

Spouses Supervisor:(Required)

Spouses Employer Phone:(Required)

Spouses Employer Address:(Required)

Street Address Address Line 2 City State ZIP Code

Spouses Position and Job Description:(Required)

Spouse seeking employment?(Required)

Yes

No

Where's the spouse currently seeking employment?(Required)

How long has the spouse been unemployed? (Months)(Required)

What steps is the spouse taking to seek active employment?(Required)

Reason for the spouse leaving last employer:(Required)

Government issued Photo ID (Front and Back)(Required)

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB, Max. files: 2.

Past Due Notice(Required)

Accepted file types: jpg, pdf, Max. file size: 8 MB.

AUTHORIZATION(Required)

I certify that the statements made above are true and complete to the best of my knowledge

By submitting this form, I certify that the statements made above are true and complete to the best of my knowledge. I give permission to POG to make inquiries as needed to determine if they are able to assist me. Offers of assistance will be based on the validity of my request, available resources and my active participation in the improvement of my financial health and well-being.

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