Apply for Financial Assistance West Region

Instructions:

If you are a resident of St. Joseph, Elkhart, Kosciusko or Marshall county only and in need of assistance, please fill out each section of this form. These questions will help determine if your family may qualify for our Resource and Referral program. 

We cannot process your request without all of this important information, so please answer every question included on the application form. Please be prepared to provide proof of household income, identification and copies of lease agreements/ bills/invoices. Click to download a copy of our Client Handbook and Participation Agreement. If appointments are available, a case manager will contact you to schedule an in-person meeting to further determine if we are able to assist you. 

If you need assistance in a different county, please visit our East Region or North Region form.

Please note: we may not be able to respond to all applications due to the extraordinary volume of requests. We genuinely empathize with your financial concerns. If we cannot help you, please see the other resources available to you below. If you receive an email from someone requesting personal information on behalf of Catholic Charities and they do not have a @ccfwsb.org email address, do not send them anything. 

Unfortunately at this time, due to a high volume of requests, we are not able to assist every applicant. If appointments are available, a case manager will contact you to gather more information to determine if we may be able to assist you.  Current wait time is several weeks.

Additional Resources:

If you or a family member needs additional resources, please call 211 or download a copy of area resources. 

Assistance Form:

Please be prepared to provide proof of household income, identification and copies of invoices/bills/lease agreements upon request.

Address
Is this address your primary residence?
Ethnicity
Race
Gender
What type of assistance are you requesting
i.e. clothing, hygiene items, diapers, etc.
Have you received assistance from other organizations toward this bill?
Is the bill/invoice in your name?

Can you provide documentation of bill(s), invoices(s), lease agreement and proof of income?

Please provide proof of household income, including applicant and other adults in the household (i.e. Statement SSI/SSDI/ TANF/ current Pay Stubs/1099/W2/ Other)

Please unload additional documentation to help determine eligibility for various programs (optional):

Are you currently employed?
If you have been directly impacted by covid, can you document being furloughed, reduced hours, loss of job or other hardship related to COVID?
Do you receive federally subsidized rental assistance through Low Income Housing Credit, Public Housing or Indiana Block Grant Housing, Housing Choice voucher, Project Based Housing?
Has anyone in your household qualified for and received unemployment benefits since April 2020?

Consent

Most funding sources and collaborative partnerships of the Resource & Referral Program require the sharing of information through reports and/or shared data collection systems. This may include but is not limited to client name, address, birth date/age, household information, demographic information, services requested and/or date, type and amount of assistance rendered including vendor and account information.  Access to and maintenance of information contained in the shared data systems or reporting documents is controlled and monitored by the entity with oversight of the data system/ report submissions, not by Catholic Charities.  In addition, Catholic Charities will release information to or obtain information from vendors or service providers for the purpose of determining client eligibility, verifying account information, making notification of assistance and coordinating assistance/ resources.  


My electronic signature acknowledges that I have applied for material and/or financial assistance from the Catholic Charities’ Resource & Referral Program.  I acknowledge reading and understanding  information contained in the Client Handbook and Participation Agreement provided in the links above. I acknowledge that I have read, understand and give consent for the release of information to and obtaining information from funders, collaborative partners, service providers and vendors as described above in the Consent Statement. I release Catholic Charities from any liability, injury, loss or damage that may result from sharing of information as described in the above Consent Statement.
 

I attest that the information provided in this application and the accompanying documentation is accurate and true.
Sign above