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Page 1

ACO
Complete the following application to be considered for services from All Community Outreach.

Only one application per household is permitted. Failure to comply will result in suspension of services. 

If other than English, select language.

Please make sure to enter the head of household first.

Head of Household
Please enter your name as it appears on your driver's license or other ID.









Please do not include $, commas or decimals

Please leave blank if you are unemployed

Complete for each member of your household, including children and adults.

SEE "ADD ANOTHER HOUSEHOLD MEMBER" UNDER EMPLOYER'S BOX BELOW

Additional Household Members









Please do not include $, commas or decimals

Please leave blank if you are unemployed

Affidavit

AGREEMENT


I certify this application has been complete to the best of my knowledge with complete & accurate information. I understand that false statements or omissions of facts relevant to my eligibility for assistance will be considered fraud and that I may be prosecuted under applicable U.S. Codes for this fraud. Furthermore, I understand that assistance granted to my household based on fraudulent information must be reimbursed in whole.


Important; Section 101 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentation to any department or agency of the United States Government as to any matter within its jurisdiction.


I am signing this Application and Affidavit by electronically entering my name below.



Page 2







Please enter your numerical 10 digit phone number, without any special characters. If you do not have a phone number contact ACO at 9727279131

Everything is tied to your email address, so please provide one you will check regularly, including spam; however, if you do not have an email address, please use the following address: none@acocares.org



Make sure to include yourself in the proper age group.








If you do not see your provider, OR see "Not available" then we are not currently able to assist with the bill.

If you do not see your provider, we are not currently able to assist with the bill.

If you do not see your provider, we are not currently able to assist with the bill.

All Community Outreach is currently focusing on assisting with utilities during this time of higher than usual utility costs to ensure the health and well-being for those in their homes, in addition to our service to fight hunger, provide household essential items, and offer programs for education and employment.  



Page 3

IMPORTANT: All documents are REQUIRED to be considered for assistance. If you do not have a document, please provide an explanation.

Please ensure that all files are clear and legible before uploading. Illegible documents will delay your application process.






You can find your bill online, if you have troubles finding it, contact your electric provider

Example: Electricity is included in my rental agreement.



Example: Water is included in my rental agreement.



Example: Gas is included in my rental agreement.



Example: I rent an apartment.


You can request a PDF file of your full signed lease from your leasing office or landlord


You can request a PDF file of your lease extension or lease renewal from your leasing office or landlord

View example here: https://www.hud.gov/sites/dfiles/OCHCO/documents/52641.pdf



Example: I own my home.



Example: I live in a zero income household.


You can find a PDF file of your recent bank statement online. If you have trouble finding it, contact your bank

Example: There is no bank account in my household.


You can reach out to the child's school administrator for the enrollment forms or contact the county office for a copy of the birth certificate



Please be aware that once all the correct documents have been submitted, you will be sent an email link to set up a meeting with a Case Director. At the time of the meeting, the Case Manager will determine the type and amount of financial assistance we will be able to assist with, if found eligible.

It is important to note, that financial assistance is not always guaranteed, however, you may be offered other types of non-financial assistance or resources instead.
Affidavit
I acknowledge that the documents submitted are correct and accurate. If they are found to be incorrect, I understand that this will delay the Intake process and possibly place my application on a 30-day suspension, where I will be unable to request assistance until after the 30 days.


Page 4

IMPORTANT: All documents are REQUIRED to be considered for assistance. If you do not have a document, please provide an explanation.

Please ensure that all files are clear and legible before uploading. Illegible documents will delay your application process.



You can find your bill online, if you have troubles finding it, contact your electric provider



Example: I rent an apartment.


You can request a PDF file of your full signed lease from your leasing office or landlord

Example: I own my home.


You can find a PDF file of your recent bank statement online. If you have trouble finding it, contact your bank

Example: There is no bank account in my household.


You can reach out to the child's school administrator for the enrollment forms or contact the county office for a copy of the birth certificate



It we require additional documentation, we will send you an email from noreply@acocares.org

Please check your spam/junk folder, as it may end up there. You will have 2 business days to resubmit your documentation, otherwise your account will be suspended for 30 days.
Affidavit
I acknowledge that the documents submitted are correct and accurate. If they are found to be incorrect, I understand that this will delay the Intake process and possibly place my application on a 30-day suspension, where I will be unable to request assistance until after the 30 days.


Page 5

Please ensure that all files are clear and legible before uploading.




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