HWAP Referral

Do you live within city limits?

Yes

No

County of Residence

Erie

Huron

Lorain

Ottawa

Sandusky

Seneca

Wood

Have you applied for HWAP before?

Yes

No

Income for all occupants over 18 years old (Select all that apply)

Self-Employed

Employed

Social Security\SSI\SSD

Public Assistance- ADC\TANF

Unemployment

Workers Compensation

Child Support

Pensions

No Income

How did you learn about our program?

Facebook, Instagram or other Social Media

Family or Friends

GLCAP Staff Member

Newspaper

Social Service Agency (Dept. of Job & Family Services, OhioMeansJobs, etc.)

Television or radio

Other

Please choose where we may send an application.

Email

Home Address

I consent to receive text messages from GLCAP

Yes