Individual & Family Assistance

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Date of Birth REQUIRED Please fill out this field. Please enter valid data.

Race/Ethnicity Asian/Pacific Islander American Indian/Alaska Native Non-Hispanic Black/African American Non-Hispanic White Hispanic/Latino (all races) Multiple Races Other

Email REQUIRED Please fill out this field. Please enter an email address.

Street Address REQUIRED Please fill out this field. Please enter valid data.

City, State REQUIRED Please fill out this field. Please enter valid data.

ZIP Code REQUIRED Please fill out this field. Please enter valid data.

Phone number REQUIRED Please fill out this field. Please enter valid data.

Spouse/Live-in Partner Please enter valid data.

Spouse/Live-in Partner's Date of Birth Please enter valid data.

Spouse/Live-in Partner's Race Please enter valid data.

Spouse/Live-in Partner's Race/Ethnicity Asian/Pacific Islander American Indian/Alaska Native Non-Hispanic Black/African-American Non-Hispanic White Hispanic/Latino (all races) Multiple Races Other

Marital Status REQUIRED Please fill out this field.

Dependent Name Please enter valid data.

Dependent Gender

Dependent Date of Birth Please enter valid data.

Dependent Name Please enter valid data.

Dependent Gender

Dependent Date of Birth Please enter valid data.

Dependent Name Please enter valid data.

Dependent Gender

Dependent Date of Birth Please enter valid data.

Dependent Name Please enter valid data.

Dependent Gender

Dependent Date of Birth Please enter valid data.

Service Requested REQUIRED

Briefly described the service you are requesting assistance for.

Please fill out this field.

Landlord/Mortgage Company Name REQUIRED Please fill out this field. Please enter valid data.

Landlord/Mortgage Company Phone Number REQUIRED Please fill out this field. Please enter valid data.

How much can you pay on the bill that you are requesting assistance with? REQUIRED Please fill out this field. Please enter valid data.

Please describe the circumstance that has led to your request for assistance. REQUIRED Please fill out this field.

Monthly Income from Employment REQUIRED Please fill out this field. Please enter valid data.

Current or Most Recent Employers REQUIRED Please fill out this field.

Other Monthly Income REQUIRED

Please include income from retirement, child support, social security/disability, SNAP, unemployment, Workman's Comp, or other income sources.

Please fill out this field. Please enter valid data.

Monthly Household Expenses REQUIRED

Please include housing expenses, utilities, and all other regular monthly expenses.

Please fill out this field.

Release of Information

By clicking "I Agree", I certify that the information I have provided in this application is true and correct. I consent to and authorize the release of pertinent information contained in the spaces in this application to/from concerned social service agencies, utility companies, landlords, and/or employers as necessary to ensure timely processing of this application and/or as a guard against duplication of assistance.

The Catholic Charities of the Diocese of Houma-Thibodaux Assistance Network, herinafter refered to as "Charity Tracker", is a shared, computerized record keeping system that captures information about people experiencing a need for emergency services, including but not limited to assistance with utility bills, medications, rent/mortgage payments etc. Catholic Charities of the Diocese of Houma-Thibodaux (Administering Agency) administers Charity Tracker on behalf of participating agencies of the Charity Tracker Assistance Network, including Catholic Charities (Participating Agency).

I authorize Catholic Charities of the Diocese of Houma-Thibodaux as a Charity Tracker Participating Agency, to share my basic, identifying and non-confidential service transactions/information with other CharityTracker Participating Agencies. I further authorize Catholic Charities (Participating Agency), as a Charity Tracker Participating Agency, to share my dependent's basic, identifying and non-confidential service transactions/information wiht other CharityTracker participating agencies.

This Release of Information will remain in effect for 3 years from the date of submission.

I Agree Please select this field.

Individual & Family Assistance

How to apply for assistance:

Online Application :

(Must live in the Diocese of Houma-Thibodaux)

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