Emergency Assistance Application

Please complete the application below as fully as possible. Providing complete and accurate information will help us understand your situation and determine whether Mountain Heart Ministries may be able to assist. Submitting an application does not guarantee assistance.

First Name *

Last Name *

Email Address *

Best Phone Number *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal code *

Household Information

Please tell us about everyone who lives in your household.

How many people live in your household, including yourself? *

Please list each person living in your household, including yourself. Include their first name, age, and relationship to you. *Example: Mary - 42- Self; John - 45 - Spouse; Emily - 12 - Daughter.

What is your household's approximate total monthly income? *Include income received by everyone in the household, such as wages, Social Security, SSI/SSDI, retirement/pensions, child support, or other regular income. Enter numbers only — do not use a dollar sign or commas. Example: Enter 1000 instead of $1,000.

What are your household's approximate total monthly expenses? *Include housing, utilities, food, transportation, insurance, medical expenses, debt payments, and other necessary household expenses. Enter numbers only — do not use a dollar sign or commas. Example: Enter 1000 instead of $1,000.

Please tell us what has happened that caused you or your family to need assistance at this time. *Please briefly explain your current situation and any circumstances that have contributed to your need.

What specific assistance are you requesting from Mountain Heart Ministries? *Please be as specific as possible. For example, tell us what bill, expense, food need, household need, or other assistance you are requesting.

Is your current need primarily a one-time emergency or an ongoing need? *One-time emergencyOngoing NeedBoth

Does anyone in your household fall into any of the following categories? *Child under 18Age 65 or olderPerson with a disabilityVeteran or active-duty military memberPregnantNone of the above

What will happen if you are unable to receive assistance with this need? *Please briefly explain how this would affect you or your household.

Have you contacted any other organization, church, agency, or assistance program for help with this need? *YesNo

If yes, please tell us who you contacted and what assistance you received or were offered.Include the name of the organization, church, agency, or program and the outcome of your request.

Is there anything else about your situation that you would like us to know?Please share any additional information that may help us understand your circumstances or your request for assistance.

What do you believe would help improve your situation going forward?

What is the best way for Mountain Heart Ministries to contact you about your application? *Phone callText messageEmail

Verification Authorization *I authorize Mountain Heart Ministries to verify the information provided in this application with appropriate individuals, organizations, agencies, landlords, utility providers, or other sources when necessary to evaluate my request for assistance.

Applicant Certification *I certify that the information I have provided in this application is true and complete to the best of my knowledge. I understand that providing false or misleading information may result in my request being denied.

Assistance Acknowledgment *I understand that submitting this application does not guarantee that Mountain Heart Ministries will provide assistance. Requests are reviewed based on individual circumstances, available resources, and the ministry’s ability to help.

Electronic Signature — Please type your full legal name *By typing my name below, I acknowledge that this serves as my electronic signature on this application.

Date *

Mountain Heart Ministries

Hope for Today • Help for Tomorrow • Faith for the Journey

Helping our Appalachian neighbors one life, one family,
and one community at a time.

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Contact

info@mountainheartministries.org

Serving mountain communities in Eastern Kentucky
and Northeast Tennessee.

“My little children, let us not love in word, neither in tongue;
but in deed and in truth.”

1 John 3:18 (KJV)

Mountain Heart Ministries is a Christian nonprofit organization
dedicated to serving individuals and families with compassion,
dignity, and hope.