Have you experienced a recent loss of income?
DO NOT FILL OUT THIS FORM IF YOU HAVE NOT YET SPOKEN WITH THE ARK.
Please fill out this form to apply for financial assistance. After completing this form, you will be asked to send in documentation verifying your loss of income. ***Please be aware that funds are limited and depending on the total of your expense, the Ark may not be able to cover your entire balance*** If we do not hear from you within 2 weeks of submitting this form, we will assume you no longer need the assistance, and your application will be removed from the queue so we can better assist those in need. Your information will be processed in the order in which it is received. Please allow 1-3 business days for the Ark to print your documentation and contact you.
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First and Last Name *
Have you ever been to the Ark before for financial assistance? *
Have you applied for or received assistance from  another agency for financial assistance in the last six months? *
If you answered YES to the previous question, please list each agency.
Are you a Publix Employee? *
Which county do you live in? (The Ark only serves the follow counties: Clarke, Oconee, Madison, and Oglethorpe unless you are Publix employee) *
Phone Number *
Email Address
Date of Birth *
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How many individuals other than yourself live in the home? List first name and date of birth. *
What is your current employment status? Select One:
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 If you are employed, what is your current hourly rate of pay (example: $12 per hour) If you are not employed, put N/A *
 If you are employed, how many hours a week do you normally work? (If you are unemployed, put zero) *
 If you receive income from a fixed source (examples include but are not limited to SSI, SSDI, UI, Worker's Comp, etc.), please list the source and monthly amount below. If you do not receive any fixed benefits, simply put N/A. *
Please take a look at this chart. Be aware that if your Gross Annual Income falls outside of these income limits, you may not be eligible for assistance. 
Employer Name and Contact Info (Email or phone) *
Reason for financial assistance *
What bill(s) do you need help with? Please select all that apply. **Selecting a bill does NOT automatically qualify you for assistance. You must meet Ark guidelines and needs will be met according to availability of funds. *
Required
For bill assistance, please check off below that you will email us the following documentation to: arkumocdocs@gmail.com or FAX 706-353-1153: (Select all that apply to YOUR circumstance) *
Required
I certify that I have not received, nor applied for, any additional Federal, State or Local assistance to pay for rental assistance OR the amount of assistance I have received from Federal, State or local agencies is less than the expenses owed for the month(s) in which I am applying. *
I hereby grant the assisting agency the right to process this application for the purpose of providing emergency assistance. Additionally, I authorize all relevant entities that provide assistance for these same purposes to release information about services provided to me for rent, mortgage and/utilities, and release them from any liability and responsibility from doing so. A photographic or faxed copy of this authorization shall be as valid as the original. *
By submitting this form I declare that the information provided throughout the application process is truthful and correct. I also understand that any willful dishonesty will result in refusal of this application and disqualification from applying for future assistance at The Ark. *
Required
Enter today's date *
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By typing your name below, you certify that the information you have provided is correct to the best of your ability and you release this information to the Ark for internal use and/or grant use. Please type your first and last name!
The Ark also provides the following free financial counseling services in combination with our special loans program. Please call the Ark (706) 548-8155 if you are interested in any of the following:
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