Five County Community Action Partnership

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.