In order for our office to provide you with the information you are looking for, please take a few minutes and complete this form and we will research based upon the information you provide services that will assist your household.

 If you are in need of emergency financial assistance we can provide you with information to other programs that offer financial assistance by completing the bottom section of this form.
Please check all the resources you need assistance finding.

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* Please check all the resources you need assistance finding.

This information is required if you would like to provide you with information and referral services.  By answering the questions on this form we can identify programs you qualify for.

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* This information is required if you would like to provide you with information and referral services.  By answering the questions on this form we can identify programs you qualify for.

Are you currently enrolled as a student?

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* Are you currently enrolled as a student?

About how long have you lived in Park County, Wyoming?

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* About how long have you lived in Park County, Wyoming?

How many people currently live in your household?

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* How many people currently live in your household?

How many people living in your household are currently 60 years or older?

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* How many people living in your household are currently 60 years or older?

What is your approximate average household income?

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* What is your approximate average household income?

Are your living quarters owned or being bought by you or someone in your household, rented for cash, or occupied without payment of cash rent?

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* Are your living quarters owned or being bought by you or someone in your household, rented for cash, or occupied without payment of cash rent?

How many people in your household have health insurance?

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* How many people in your household have health insurance?

How many people in your household are disabled?

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* How many people in your household are disabled?

How many services have been able to access services you found on our website?

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* How many services have been able to access services you found on our website?

What information would you like to see our company provide?

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* What information would you like to see our company provide?

How likely is it that you would recommend our website to a friend or colleague?

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* How likely is it that you would recommend our website to a friend or colleague?

Not at all likely
Extremely likely
What type of device did you use to take this survey?

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* What type of device did you use to take this survey?

Which of the following applies to your current situation?

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* Which of the following applies to your current situation?

If you need emergency financial assistance was is the amount you are seeking?

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* If you need emergency financial assistance was is the amount you are seeking?

Please provide us with a summary of your request, briefly explain your situation, and what resources are in place to ensure you will be able to resume payments next month.

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* Please provide us with a summary of your request, briefly explain your situation, and what resources are in place to ensure you will be able to resume payments next month.

What is your?

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* What is your?

What is your current monthly income?

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* What is your current monthly income?

Does your household have a support system in place? Please explain. 

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* Does your household have a support system in place? Please explain. 

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