School Supplies Application

Please complete this form to request school supplies.

School Supplies Application
Please complete this short form to request school supplies. School supplies are only available to households living in Cedar, Clinton, and Muscatine Counties in Iowa.

What Is Your Address?

Street Address *
Street Address
City
State/Province
Zip/Postal

Head of Household

If homeless, check here

Household Member 2

Household Member 3

Household Member 4

Household Member 5

Household Member 6

Income

Household Size200% Poverty Limit
1$25,520
2$34,480
3$43,440
4$52,400
5$61,360
6$70,320
Self-Declaration of Income *
Your Mailing Address
Your Mailing Address
City
State/Province
Zip/Postal
What County Do You Live In? *
We're sorry. We can only provide school supplies assistance to residents of Cedar, Clinton, and Muscatine Counties. Your application will be denied.
Your child(ren) may be eligible for help with tennis shoes through the United Way’s Significant Soles program. Would you like information on how to apply? If you check yes, you are agreeing to allow us to share your information with the United Way of Muscatine. *
By checking the box below you are signing this application and you are agreeing that all of the information you provided is true and accurate. You are also asserting that you will use any gift card(s) you receive only for the purchase of school supplies for children in grades K-12 who live in your household. *