United Way | Benefits Navigator

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Please provide some information about your household

Marital Status *

Adults 19 - 64 (including yourself)

Do you have any children?

yes no

Adults 65+

Do you, or does any other adult in your household have a disability or long-term illness or injury?

Are you adding a child to your family through birth or adoption in the near future?

Child 1 Age

Child 2 Age

Child 3 Age

Child 4 Age

Child 5 Age

Child 6 Age

Child 7 Age

Do any of these children have a disability?

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Please provide a few income details

Are you currently unemployed?

Total Annual Household Income (estimated, before-tax) *

This includes, but is not limited to, employment income, child/spousal support payments, other household members' income, any benefits you are currently receiving.

Municipality of Residence

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