Good Samaritan Fund Application

The Good Samaritan Fund at St. Luke's is designed to provide assistance to members of our church and the wider community who are experiencing difficulties paying overdue or past due rent and utility bills. Please note that the fund does not cover hotel bills

Applicants Must Reside in York County or Poquoson

Application cut off is 6pm each Wednesday

A Client Advocate will reach out to you No later than Monday of the next week.

Our funds are limited so we are only able to help each client once per 12 month period. There is a lifetime maximum per client of $750

Due to limited funds we can only accept 5 clients per week. If that number is exceeded, you will receive an e-mail that we cannot help in that week.

Date

First

Middle Initial IF your middle initial is indicated on your billl

Address

Phone

While e-mail is not required if you provide one you will get immediate conformation that your request has been submitted

This address will receive a confirmation email

Last 4 of SSAN

Type of Assistance Requested

If Rent is Requested Then Fill out the following information

In most cases if you are requesting Rent assistance you must notifiy the leasing agent giving them permission to discuss your rent situation with the advocate working your request

Leasing Agent

Address

Leasing Agent phone number

Past Due amount

Do you have an eviction notice and if so what is the scheduled eviction date.

If Utility Assistance is requested then fill out the following information

Utility Name

Address

Account Number

Any Other Information we might need to know about your request?

Description

Please fill out this form and click submit.

Good Samaritan Fund Application

Description

Please Fix the Following