Apply For Help

Download PDF Application

 

Application for Assistance

READ THIS DISCLAIMER CAREFULLY: It is the desire of Lake George WIN to assist the applicant with their current need. Please understand that WIN cannot assist all applicants. WIN is a public charitable organization and does not receive any funding from either the state or federal government. WIN relies on your statements below in making decisions on granting assistance and it is in WIN’s sole discretion as to the applications that will be approved and the extent of assistance available. WIN DOES NOT GUARANTEE TO PROTECT YOUR CONFIDENTIALITY but will attempt to keep your information as private as possible.

Please read the attestation statement at the end of your application.

Name of Applicant
Address

City
State

Zip
Email

Phone
DOB

Status


Referred By

Please provide an explanation describing your current need:
Please note: if you are applying for assistance for rent, the maximum rent payment allowable is limited to $500.00 and will be paid to the landlord of the rental property. You must include the name, address, and phone number of the landlord. WIN does not provide funds for security deposits.

Are you currently working?



Please list the name, age, occupation and monthly income of all other adults in your household:

Position
Employer Name

Phone
Income

Do you, or does anyone in your household, receive the following? If yes, please provide the monthly dollar amount:

Unemployment Benefits


Amount

Social Security Benefits


Amount

Disability Payments


Amount

Child Support


Amount

SNAP (Food Stamps)


Amount

WIC


Amount

Heating Assistance


Amount

Housing Assistance


Amount

Temporary Assistance Grant


Amount

Section 8 Voucher


Amount

Are you receiving any other aid from “private organizations” not funded by county, state or federal government?


Do you know any member of WIN?



If yes, explain the type of aid and amount received:
If yes, Name

Phone
How do you know the member?

Please list the ages of all children in your household under the age of 18:
Please provide the names and contact information for 2 references (individuals or agencies) who can attest to your current situation:

I have answered all the questions above and attest that the information is true. I give consent to WIN to contact any
individual, whether noted in this application or not, to validate my situation. I understand that WIN may or may not be
able to provide assistance. I acknowledge I have read and understand the disclaimer above and accept it.

Signature of Individual in Need
Date

An Incomplete Application Will Be Returned.