Print Paper Application:
It should include all household members (even if living with friends and family). Income verification is required for all household members over 18. Income should be verified through the following methods:
- Last 30 days of earned income
- Last 30 days of bank statement
- Benefit letters (SSDI / SSI)
- W2(‘s) or previous tax return
- DWS Employer Verification Form (Form ESD 630)
- Self-Declaration of Income (for self-employment or no income) (not the preferred method and to be used only after all other resources have been exhausted – may also slow down application).
Once the application is complete, please call 435-674-5757 and leave a message on the general assistance voicemail. You can also email your application to amerrill@fivecounty.utah.gov. A staff person will follow-up and schedule an appointment. Please allow 3 business days for a response.
Please note: Due to staff constraints, we may not be able too serve walk-in appointments.
Five County Community Action Partnership 