Do I qualify? First name Last name Phone number ZIP code County Choose one Travis Hays Other If approved for assistance, are you able to attend an in-person appointment? Yes No We are only able to assist through in-person appointments at our physical location. If you are not able to attend in-person appointments for any reason, call 2-1-1 or visit www.findhelp.org for more options. Are you seeking Rental, Utility or Prescription assistance? Choose one Rental Utility Prescription Are you seeking rental assistance for this month's rent (or previous month) or next month's rent? Choose one This month or previous month Next month Do you currently owe less than $100 on your rent? Yes No Do you pay rent to a commercial landlord (such as an apartment complex) or a property management company? Yes No Please list the company name Do they accept third-party checks? Yes No Are you needing help with a light, gas or water bill? Choose one Electric Bill Gas Bill Water Bill Other Are you seeking utility assistance for this month's bill (or previous month) or next month's bill? Choose one This month or previous month Next month Do you currently owe less than $50 on your utility bill? Yes No Does your utility company accept third-party checks? Yes No Are you seeking assistance with paying for a prescription at a pharmacy? Yes No Do you currently owe less than $50 on your prescription(s) altogether or on at least one prescription? Yes No Does your pharmacy accept third-party checks? Yes No Are you able to get a list with the costs of your prescriptions/medications from your pharmacy? Yes No Submit form Thank you — we received your answers. Our team will review your information and contact you at the phone number you provided.
