What services are you applying for?

Applicant Name *

Address *

Number in Family *

Home Phone *

Work Phone

Cell Phone

Is applicant, spouse or other adults employed? *

If not employed, did you lose your job due to COVID-19? *

Were your hours reduced due to COVID-19? *

If you did not lose your job or had hours reduced, what circumstance occurred that rendered you unable to pay? 

Total Amount Past Due:

Rent:

Mortgage:

Electric:

Gas:

Water:

Coronavius Aid Relief Application

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1000 West Minnesota Avenue

Chickasha, OK 73018

info@washitavalleycac.com

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