ATTENTION

In 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 *

First

Middle

Last

Enter 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? *

Have you ever been charged or convicted of a drug-related felony? *

Email *

Current Physical Address *

Address Line 1

City

State

Zip Code

County of Residence *

Phone *

ex. (123) 456-7890

Household Information

How many family members are in your household (not including yourself)? *

Name of each family member, age, & relationship to you *

What is the annual combined household income of all household members 18 and older? *

ex. $12,345

My household is (check all that apply): *

Eligible for/enrolled in Medicaid
Eligible for/receiving Families First (TANF) benefits
Eligible for/receiving Supplemental Nutrition Assistance Program (SNAP) benefits; formerly known as food stamps
Receiving Section 8 housing or low-rent public housing
Receiving free or reduced lunch
None of the above

Empower UC Feedback

Please describe the main reason your are interested in applying for the Empower UC Program: *

How did you hear/learn about Empower UC? *

If you selected "Other" above, please provide additional details below

Understanding 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? *

This 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? *

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? *

Current Life Situation

Housing Stability: Do you have a stable place to live? *

Yes
No
Temporarily staying with others
At risk of losing housing

Employment & Income Stability: Is at least one adult in your household employed? *

Yes, Full-time
Yes, Part-time
No
Seeking employment

Crisis Indicators: Has your household experienced any of the following in the past 30 days? (Check all that apply) *

Authorization *

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 *