Service Request

Please complete the following information in order for us to advance your application.

If you need assistance completing this application, please call 1-715-598-4750.

First Name *

Last Name *

Last 4 digits of Social Security *

Date of Birth *

Property Address *

City *

State *

Zip Code *

Do you have a different mailing address? *

Yes

No

Mailing Address (if different than Property Address):

City

State

Zip Code

County of Residence *

County of Residence

Housing Status *

Please explain your housing status:

Cell Phone or Main Phone Number: *

Other Phone Number:

Email Address

Other Contact Information:

*No Heat Emergency or Low Fuel/Disconnection, call our office at 715-598-4750 option 2

**Utility Assistance (help with payment of electricity or heat) call our office at 715-598-4750 option 1

***Renter Assistance (help with payment of rent) call our office at 715-598-4750 option 1

Which service can West CAP assist you with? *

Are you or anyone in the household a friend or family member to any West CAP employee or Board of Director? *

Yes

No

EEOC Statement:

West CAP is an equal opportunity organization and no otherwise qualified applicant for service or service participant shall be excluded for participation, be denied benefits, or otherwise be subject to discrimination in any manner or on the basis of race, color, national origin or ancestry, sex, religion, age, political belief or affiliation, disability or association with a person with a disability. This policy covers eligibility for the access to service delivery, and treatment in all of the programs and activities.

With my signature, I authorize West CAP to release information stated on this form and/or in my case/project files to designated staff and/or other agencies to which my case/project pertains. I have voluntarily provided the information above and it is true and correct to the best of my knowledge. I am aware that providing false information or not reporting pertinent information is fraud. If I provide any false information, I understand that services may be denied. I understand that completion of this application does not guarantee that I will receive assistance. I also understand that the information will be held in confidence and used specifically to determine eligibility and program planning.

Signature *

Date * +