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Take the first step, apply for help now.

Start the process before paying us a visit.

Please fill out the form below that will be sent to our team for review. Be advised that this application is strictly confidential. Any information regarding sex, ethnicity, education, or disability is gathered for reporting to funding sources only. This agency does not discriminate in any way in provision of services. For information you find sensitive that you would like to share, please call us directly at 716-881-5150.

    Head of Household

    First Name*
    Last Name*
    Date of Birth
    Address*
    City*
    Zip Code*
    Phone Number:
    Gender: MaleFemaleOther

    Age: 0-56-1314-1718-2425-4445-5455-5960-6465-7475+
    Education Level: Grades 0-8Grades 9-12 / Non-GraduateHS Graduate / Equivalency Diploma12 Grade + Some Post-Secondary2 or 4 Years College GraduateGraduate or Other Post-Secondary School

    Housing: OwnRentOther Permanent HousingHomelessOther
    Number of Youths Ages 14-24 Neither Working or in School:

    Work Status: Employed Full-TimeEmployed Part-TimeMigrant Seasonal WorkerUnemployed (Short-term, 6 months or less)Unemployed (Long-term, more than 6 months)Unemployed (Not in labor force)Retired
    Disabling Condition: YesNo

    Health Insurance: YesNo
    Health Information: MedicaidMedicareState Health Insurance for AdultsState Children's Health Insurance ProgramMilitary Health CareDirect-PurchaseEmployment Based

    Ethnicity - Hispanic, Latin, Spanish Origins: YesNoUnknown / Not Reported
    Race: American Indian or Alaska NativeAsianBlack / African-AmericanNative Hawaiian and Other Pacific IslanderWhiteOtherMulti-Race (Any 2 or more above)

    Head of Household Source of Income and Benefits

    Fill in that apply and list the amount received. Indicate Yearly, Monthly, or Weekly amount by writing amount as follows: Yearly 15,000.

    No Income Yes
    Employment
    TANF
    SSI (Supplemental Security Income)
    Social Security Disability Compensation
    VA Non-Service Connected Disability Pension
    VA Service-Connected Disability Compensation
    Private Disability Insurance
    Workers Comp / Disability Insurance
    Retirement Income from SS
    Pension
    Child Support
    Alimony / Spousal Support
    Unemployment Insurance
    EITC
    Other

    Please use the totals above to calculate the Household Annual Income

    Total Annual Income:

    Non-Cash Benefits (Please check all that apply): SNAPHousing Choice VoucherChildcare VoucherHUD-VASHPermanent Supportive HousingWICAffordable Care Act SubsidyPublic HousingLIHEAPOther

    Additional Household Members

    First Name:
    Last Name:
    Middle Initial:
    Date of Birth:
    Disabled: YesNo
    Active Military: YesNo
    Veteran: YesNo
    How is this person related to you:

    First Name:
    Last Name:
    Middle Initial:
    Date of Birth:
    Disabled: YesNo
    Active Military: YesNo
    Veteran: YesNo
    How is this person related to you:

    First Name:
    Last Name:
    Middle Initial:
    Date of Birth:
    Disabled: YesNo
    Active Military: YesNo
    Veteran: YesNo
    How is this person related to you:

    First Name:
    Last Name:
    Middle Initial:
    Date of Birth:
    Disabled: YesNo
    Active Military: YesNo
    Veteran: YesNo
    How is this person related to you:

    First Name:
    Last Name:
    Middle Initial:
    Date of Birth:
    Disabled: YesNo
    Active Military: YesNo
    Veteran: YesNo
    How is this person related to you:

    First Name:
    Last Name:
    Middle Initial:
    Date of Birth:
    Disabled: YesNo
    Active Military: YesNo
    Veteran: YesNo
    How is this person related to you:

    Requesting Assistance With: HousingHealth / Medical ServicesEmploymentEmergency ServicesSocial ServicesFoodClothingUtilitiesFinance DevelopmentDay CareEducationSenior ServicesCommunity DevelopmentLegal Aid
    Other:
    Notes or comments: