Catholic Charities serves all people regardless of their religion, race or ethnicity. If you are in need of services or support, please fill out the form below. Once submitted one of our staff will reach out to you. Contact InfoFull Name(Required) First Last Email(Required) Phone(Required)Home InfoFull Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code County(Required) Gross Monthly Income(Required)including income of all persons in the home Number of persons in the home(Required) Financial Documents(Required)Please attach any financial documents to prove income (FOR THE LAST 30 DAYS). SNAP ( welfare documents), SSI Income, Wages income, Retirement Benefits . if you are ZERO income you must provide paperwork from the welfare office supporting that. Drop files here or Select files Max. file size: 900 MB. Service Request InfoI Received Past Help(Required)Have you received help from Catholic Charities before? YES NO Catholic charities help(Required)Briefly list when you received help and for what. I received Other Agencies Help(Required)Are you working with any other agencies at this time? YES NO Agencies Help(Required)Briefly list what agencies helped and how much . Utility InfoName of utility(Required) Utility account number(Required) Utility named account(Required)Is the utility in a personal name or in your landlords name? If in the landlord name then you are REQUIRED TO PROVIDE US A LEASE. Personal Name Landlord Name Personal Name on utility(Required) Landlord name on utility(Required) Landlord Lease(Required)YOU MUST SUPPLY THE LEASE. Upload /attache it here Drop files here or Select files Max. file size: 900 MB. Utility BillingDo you have a termination(Required) YES NO Terminination Amount(Required) Termination Date(Required) Termination Document(Required)Please upload your termination document. Take a picture or scan it in and attache it here. Drop files here or Select files Max. file size: 900 MB. Is the service on or off(Required) ON OFF Date of last payment(Required) Amount of last payment(Required) Reason you cannot pay the bill(Required)Can you contribute to the bill?(Required) YES NO Contribute Amount(Required)How much can you contribute per month? FundingPast Funding Received(Required)Have you received funding in the past 12 to 24 months ? YES NO Funding from who?(Required) Funding for what?(Required) Funding Amount(Required)How much funding did you receive? COVIDCovid related hardship(Required)Have you experiences a Covid related hardship YES NO Explan your COVID hardship(Required)Loss of income? loss of job? Medical issue?LIHEAPThe Low Income Home Energy Assistance Program (LIHEAP) helps families living on low incomes pay their heating bills in the form of a cash grant.I applied for LIHEAP-Crisis(Required) YES NO LIHEAP Utilities Applied for(Required)What LIHEAP utilities did you apply for? gas/electric heating fuel (oil, coal, propane,wood) I received LIHEAP-Crisis(Required) YES NO Utility you received for LIHEAP?(Required)List all the utilities you received money from LIHEAP for. LIHEAP-Crisis amount received(Required)List the amount you received from LIHEAP-Crisis Oil Fuel SourceOil Fuel Source(Required)Do you have oil as a fuel source? YES NO Oil UtilityHave you purchased oil yourself this season?(Required) YES NO Oil company(Required) Oil company account info(Required)Provide your full address AND account number for your oil company. If you do not have your account number then just provide your full address. I applied for oil LIHEAP-Crisis(Required) YES NO What oil utility did you apply for?(Required)List all the utilities you applied for LIHEAP. I received oil LIHEAP-Crisis(Required) YES NO Oil Utility you received for LIHEAP?(Required)List all the oil utilities you received money from LIHEAP for. LIHEAP oil amount received(Required) Reason you cannot pay for oil delivery(Required)LIHWAPThe Low Income Household Water Assistance Program (LIHWAP) is a temporary emergency program to help lowincome families pay overdue water bills. I applied for LIHWAP(Required) YES NO What LIHWAP utility did you apply for?(Required)List what you applied for - water and/or sewage in the box below. I received LIHWAP(Required) YES NO Utility you received for LIHWAP?(Required)List all the utilities you received money from LIHWAP for. LIHWAP amount received(Required) CommentsThis field is for validation purposes and should be left unchanged.