Request Assistance

To best assist you, we use a database to manage our services. Your information is visible to a limited number of human service providers and protected using the highest standards. Law enforcement has no access to this system. Allowing your information to be viewed allows us to better serve you. You’ll have improved access to potential services such as basic needs, employment and housing. This information will also help us understand our community needs and is used to advocate for funding. If you have any questions or would like a copy of the Privacy Notice or would like to request limited visibility, please let a CAPNC staff member know.

Additionally, to better assist you with possible services, Community Action Partnership of Natrona County requests to obtain information from any and all federal, state, county or city agencies, employers, landlords (past, present and prospective) and utility providers, and all entities listed below as necessary to verify statements given in this application. By signing below I/we authorize this access and I/we understand that any knowing or unknowing failure to provide accurate income or household information may result in denial of service. I/we understand that completion of this application is not a guarantee of benefit and that the decision to assist is based on (but not limited to): need, order of application, previous assistance, income qualification and available funding.

Note: This Release of Information will expire one year from date of signature, unless otherwise documented.

All questions need to be answered for each household member.

Please fill out this section completely. If an item does not apply, enter NA in the space.

Enter NA if not applicable.

The following information will enable us to effectively serve you but will not be factored into eligibility.

FAILURE TO PROVIDE DOCUMENTS LISTED BELOW WILL RESULT IN DELAY AND POSSIBLE DENIAL OF SERVICES.

Applicants claiming zero income must complete and sign a certification of zero income form.