Our Leadership - Couleecap Inc

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Application for Critical Bill Payment Assistance Program

* Indicates required field

Name *

First

Last

DATE OF BIRTH *

ADDRESS *

SIZE OF HOUSEHOLD *

CITY *

STATE *

ZIP *

Email *

1. Reason for needing assistance? *

Loss of hours at work Laid-off for unknown time Lost job

2. Date of loss of work/wages? *

Untitled *

What is your age? *

Less than 13 13-18 19-25 26-35 36-50 Over 50 Prefer not to say

What is your household income? *

Less than $10,000 $10,001 - $25,000 $25,001 - $40,000 $40,001 - $70,000 $70,001 - $100,000 Greater than $100,000 Prefer not to say

Submit

Hetti Brown - Executive Director

Kim Cable - Housing & Community Services Director

Amy Felber - Chief Financial Officer

Ashley Lacenski - Community Development Director

Tom Mayne - Energy Services Director

Courtney Messer - Human Resource Manager

Shelly Teadt - Director of Planning

Copyright © 2018 Couleecap Inc

Home
About
- Our Board
- Our History >
  - Our Reports >
    
    2019 Needs Assessment
    
    2019 Impact Report
    
    2018 Impact Report
Programs
News
Careers
- Current Opportunities
Contact Us
- Donate >
  - Our Stories
- Consumer Information
Golf