Alienum phaedrum torquatos nec eu, vis detraxit periculis ex, nihil expetendis in mei. Mei an pericula euripidis, hinc partem.

Apply Now

Take the first step, apply for help now.

Start the process before paying us a visit.

Please fill out the form below that will be sent to our team for review. Be advised that this application is strictly confidential. Any information regarding sex, ethnicity, education, or disability is gathered for reporting to funding sources only. This agency does not discriminate in any way in provision of services. For information you find sensitive that you would like to share, please call us directly at 716-881-5150.

Head of Household

First Name*
Last Name*
Date of Birth
Address*
City*
Zip Code*
Phone Number:
Gender: MaleFemaleOther

Age: 0-56-1314-1718-2425-4445-5455-5960-6465-7475+
Education Level: Grades 0-8Grades 9-12 / Non-GraduateHS Graduate / Equivalency Diploma12 Grade + Some Post-Secondary2 or 4 Years College GraduateGraduate or Other Post-Secondary School

Housing: OwnRentOther Permanent HousingHomelessOther
Number of Youths Ages 14-24 Neither Working or in School:

Work Status: Employed Full-TimeEmployed Part-TimeMigrant Seasonal WorkerUnemployed (Short-term, 6 months or less)Unemployed (Long-term, more than 6 months)Unemployed (Not in labor force)Retired
Disabling Condition: YesNo

Health Insurance: YesNo
Health Information: MedicaidMedicareState Health Insurance for AdultsState Children's Health Insurance ProgramMilitary Health CareDirect-PurchaseEmployment Based

Ethnicity - Hispanic, Latin, Spanish Origins: YesNoUnknown / Not Reported
Race: American Indian or Alaska NativeAsianBlack / African-AmericanNative Hawaiian and Other Pacific IslanderWhiteOtherMulti-Race (Any 2 or more above)

Head of Household Source of Income and Benefits

Fill in that apply and list the amount received. Indicate Yearly, Monthly, or Weekly amount by writing amount as follows: Yearly 15,000.

No Income Yes
Employment
TANF
SSI (Supplemental Security Income)
Social Security Disability Compensation
VA Non-Service Connected Disability Pension
VA Service-Connected Disability Compensation
Private Disability Insurance
Workers Comp / Disability Insurance
Retirement Income from SS
Pension
Child Support
Alimony / Spousal Support
Unemployment Insurance
EITC
Other

Please use the totals above to calculate the Household Annual Income

Total Annual Income:

Non-Cash Benefits (Please check all that apply): SNAPHousing Choice VoucherChildcare VoucherHUD-VASHPermanent Supportive HousingWICAffordable Care Act SubsidyPublic HousingLIHEAPOther

Additional Household Members

First Name:
Last Name:
Middle Initial:
Date of Birth:
Disabled: YesNo
Active Military: YesNo
Veteran: YesNo
How is this person related to you:

First Name:
Last Name:
Middle Initial:
Date of Birth:
Disabled: YesNo
Active Military: YesNo
Veteran: YesNo
How is this person related to you:

First Name:
Last Name:
Middle Initial:
Date of Birth:
Disabled: YesNo
Active Military: YesNo
Veteran: YesNo
How is this person related to you:

First Name:
Last Name:
Middle Initial:
Date of Birth:
Disabled: YesNo
Active Military: YesNo
Veteran: YesNo
How is this person related to you:

First Name:
Last Name:
Middle Initial:
Date of Birth:
Disabled: YesNo
Active Military: YesNo
Veteran: YesNo
How is this person related to you:

First Name:
Last Name:
Middle Initial:
Date of Birth:
Disabled: YesNo
Active Military: YesNo
Veteran: YesNo
How is this person related to you:

Requesting Assistance With: HousingHealth / Medical ServicesEmploymentEmergency ServicesSocial ServicesFoodClothingUtilitiesFinance DevelopmentDay CareEducationSenior ServicesCommunity DevelopmentLegal Aid
Other:
Notes or comments: