United Way of Southern Chester County

Personal Information

First Name *

Middle Name

Last Name *

Phone *

Email Address

Date of Birth *

Street Address *

State *

Zip Code *

Primary Spoken Language *

Eligibility Questions

Do you live within one of the following school districts: Avon Grove, Kennett, Oxford, or Unionville-Chadds Ford? *

Yes

Have you served in the United States military? *

Yes

Program Selection

Please select ONE of the following that applies to you: *

I am applying for up to $500 towards car repair (Lift ALICE Up)

I am applying for Financial Education Training

Vehicle Documentation

Do you have a valid driver's license? *

Yes

Upload Driver's License Documentation

Accepted formats: PDF, JPG, PNG

Do you have an up-to-date vehicle registration? *

Yes

Upload Registration Documentation

Accepted formats: PDF, JPG, PNG

Do you have valid vehicle insurance? *

Yes

Upload Insurance Documentation

Accepted formats: PDF, JPG, PNG

Auto Repair Shop Name *

Auto Shop Phone Number *

Upload Repair Estimate *

Upload your documented need (a repair estimate) for the vehicle to pass state inspection or to ensure the vehicle's safety.

Employment & Income

Do you currently earn wages from full-time work, part-time, or self-employment? *

Yes

Employer Name *

Annual Household Income *

Employer Address

Household Size *

Additional Information

If you have children, are any of your children in daycare? *

Yes

N/A

Do you or anyone in your family receive any of the following? *

Child Support, Supplemental Nutrition Assistance Program (SNAP), Temporary Cash Assistance, Housing Allowance, Utility Assistance

Yes

Are you able to save at least $50 per month? *

Yes

What is your six-month dollar amount savings goal?

How Did You Hear About Us?

How did you hear about our programs?

Certification

By checking this box, I certify that the above information is true to the best of my knowledge.

United Way ALICE Pre-Qualification Survey