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.

Email *

Current Address

Address Line 1

Address Line 2

City

State

Zip Code

County of Residence *

Phone *

ex. (123) 456-7890

Household Information

How many family members in your household? *

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

What is the annual combined household income of all family 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

How would you rate your current circumstances overall? *

In Crisis - Has neither the financial support nor resources to support the family’s basic needs.	Vulnerable - Has to heavily rely on outside resources combined with limited household financial support to meet the family’s basic needs	Safe and Stable- Has resources and household financial support to meet the family’s basic needs with subsidies requiring occasional assistance from outside resources to supplement some basic needs	Building Capacity - Has newly acquired strong household financial support that is able to meet the family’s basic needs only requiring some subsidies.	Empowered - Has strong, long-standing household financial support to meet the family’s basic needs requiring no assistance from outside resources or subsidies.
In Crisis - Has neither the financial support nor resources to support the family’s basic needs.In Crisis - Has neither the financial support nor resources to support the family’s basic needs.	Vulnerable - Has to heavily rely on outside resources combined with limited household financial support to meet the family’s basic needsVulnerable - Has to heavily rely on outside resources combined with limited household financial support to meet the family’s basic needs	Safe and Stable- Has resources and household financial support to meet the family’s basic needs with subsidies requiring occasional assistance from outside resources to supplement some basic needsSafe and Stable- Has resources and household financial support to meet the family’s basic needs with subsidies requiring occasional assistance from outside resources to supplement some basic needs	Building Capacity - Has newly acquired strong household financial support that is able to meet the family’s basic needs only requiring some subsidies.Building Capacity - Has newly acquired strong household financial support that is able to meet the family’s basic needs only requiring some subsidies.	Empowered - Has strong, long-standing household financial support to meet the family’s basic needs requiring no assistance from outside resources or subsidies.Empowered - Has strong, long-standing household financial support to meet the family’s basic needs requiring no assistance from outside resources or subsidies.

Empower UC Feedback

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Final Steps

I am completing this form on behalf of *

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 *

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Applicant Information

ATTENTION

Household Information

Empower UC Feedback

Final Steps