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. Eligible applicants must meet income guidelines and will be served on a first-come, first-served basis until funds are depleted. 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.

Are you age 18 years or older? *

Yes

No

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

Yes

No

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 will not be shared with your employer. *

What is your legal first name? *

What is your legal last name? *

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

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

Yes

No

Email address *

Street Address *

City *

State *

ZIP Code *

What is the total income your household expects to earn in 2020? *

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

Yes

No

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

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.

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

Please upload your 2019 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 your most recent pay stub (within the last 60 days) 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. *

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. *

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