Apply for Services Please enable JavaScript in your browser to complete this form.Applicant InformationDo you have a child/children in the household? *YesNoATTENTIONIn order to be eligible for Empower Upper Cumberland, you must have a child/children in the household. If you do not have a child/children in the household, please visit https://uchra.org/service-coordination-form/ to learn about other assistance opportunities. Name *FirstMiddleLastEnter your first and last name as well as your middle initial in the fields above. Today's Date *Date of Birth *Last four (4) of SSN *Enter the last four (4) digits of your Social Security number here.What is your Citizenship status? *Please choose one U.S. CitizenLegal/ Permanent ResidentNot a U.S. CitizenRefugee/ AsyleeHave you ever been charged or convicted of a drug-related felony? *Please choose one YesNoEmail *Current Physical Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCounty of Residence *Please choose one CannonClayCumberlandDeKalbFentressJacksonMaconOvertonPickettPutnamSmithVan BurenWarrenWhitePhone *ex. (123) 456-7890Household InformationHow many family members are in your household (not including yourself)? *Please choose one 1234567 or moreName of each family member, age, & relationship to you *What is the annual combined household income of all household members 18 and older? *ex. $12,345My household is (check all that apply): *Eligible for/enrolled in MedicaidEligible for/receiving Families First (TANF) benefitsEligible for/receiving Supplemental Nutrition Assistance Program (SNAP) benefits; formerly known as food stampsReceiving Section 8 housing or low-rent public housingReceiving free or reduced lunchNone of the aboveEmpower UC FeedbackPlease describe the main reason your are interested in applying for the Empower UC Program: *How did you hear/learn about Empower UC? *Please choose one DHSSocial MediaWebsiteAdvertisement (radio, other)Community Partner/Word of MouthNewspaper/RadioOtherIf you selected "Other" above, please provide additional details belowUnderstanding and Finalizing Your Commitment Empower UC is not a supplemental income program. It is a program that helps people learn new skills, find better jobs, and increase their income. Participation in all required program activities is essential for continued support. Do you understand that engagement and commitment to program requirements are necessary to receive assistance? *Please choose oneYes, I understand and will participateNo, I do not want to participateThis is a workforce development program. Are you ready, willing, and able to actively participate in improving your job skills, increasing your wages, and finding better employment opportunities? *Please choose one Yes, I understand and will participate.No, I do not want to participate.Participation in this program requires a personal commitment of 5-10 hours per week in activities focused on your well-being, personal growth, and the establishment of SMART goals (Specific, Measurable, Achievable, Relevant, and Time-bound). This commitment is essential for your success. Are you able and willing to dedicate this time each week to fully participate in the program? *Please choose one Yes, I understand and will participate.No, I do not want to participate.General Stability Indicators Housing Stability: Do you have a stable place to live? *YesNoTemporarily staying with othersAt risk of losing housingEmployment & Income Stability: Is at least one adult in your household employed? *Yes, Full-timeYes, Part-timeNoSeeking employmentCrisis Indicators: Has your household experienced any of the following in the past 30 days? (Check all that apply) *Job lossEviction or risk of losing housingUtility shut-offUnsafe living conditionsOtherAuthorization *I hereby agree that the information I have provided is accurate, to the best of my knowledge, at the time of submission.Signature of Person Completing Application *Clear SignatureSubmit Amye Anderson2024-02-14T14:58:12+00:00February 14th, 2024|Uncategorized|Comments Off on Apply for Services Share This Story, Choose Your Platform! FacebookTwitterLinkedInEmail Related Posts Empower Upper Cumberland Project Summit Booklet Gallery Empower Upper Cumberland Project Summit Booklet