Pocono Mountains United Way's Hospitality and Restaurant Worker Relief Fund

The following information is required and will be used to verify eligibility for Pocono Mountains United Way's Hospitality and Restaurant Worker Relief Fund. Please provide accurate contact information so that we can contact you with any follow-up questions about your application and to notify you if you are selected to receive financial assistance. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED.

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What is your legal first name? *

What is your legal last name? *

Are you age 18 years or older? *

Yes

No

Daytime phone number (enter numbers only, no dashes or spaces, ex. 5701234567) *

Are you able to receive text messages on this phone? *

Yes

No

Email Address *

Street Address *

City *

State *

Zip Code *

What county do you live in? *

What county do you work in? *

Are you currently employed or have been employed in the last 60 days by a restaurant or hospitality business? *

Yes

No

Please provide the name of your employer. This application will not be shared with your employer. *

What is the total income your household expects to earn in 2022? *

How many children under the age of 18 currently live in your household? In none, select "0". *

Is your household income at or below the amounts shown above based on your household size? *

Yes

No

Have your wages or the wages of others in your household been negatively impacted by the COVID-19 pandemic? *

Yes

No

PLEASE PROVIDE ANY ADDITIONAL COMMENTS OR INFORMATION ABOUT YOUR HOUSEHOLD AND NEED FOR FINANCIAL ASSISTANCE. *

Please upload estimates/quotes from contractors or vendors.

Please upload your 2021 tax return (IRS Form 1040 or 1040-SR) to verify your eligibility for the fund. Please block out any Social Security Numbers (SSNs) listed on the tax return. PLEASE VIEW THE SAMPLE TAX RETURN BELOW to ensure all required information is visible and that you are uploading the correct document. *

Please upload all paystubs from the last 60 days for all adults in the household to verify your eligibility for the fund. Please block out ALL information except your name, the date of the pay stub, and the name of your employer. PLEASE VIEW THE SAMPLE PAY STUB BELOW to ensure all required information is visible and that you are uploading the correct document. *

Please upload a picture of your Driver's License or other state-issued ID. *

Are you a family member or do you reside in the same household as a staff or board member of Pocono Mountains United Way? *

Yes

No

If yes, enter the name of the staff or board member.

By selecting "YES", you are certifying that everything within this application is true and accurate to the best of your knowledge. *

Yes

By signing this form and clicking submit you agree and consent that all information provided on this application, including any and all personal and financial data, is accurate and will be used to evaluate your application for the Hospitality and Restaurant Worker Relief Fund. You also agree that you will use any funds provided to address immediate basic needs for yourself and/or your dependents, including rent, transportation, medical expenses, or food. The information entered on this form is confidential and will be stored by Pocono Mountains United Way indefinitely.

I acknowledge that assistance under the Pocono Mountains United Way’s Hospitality and Restaurant Worker Relief Fund is contingent upon, amongst other criteria, my full name, account/invoice/quote number (if applicable), and application status being provided to the third-party payee identified in this application. *

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