Winter Coats

Student Coat Program

The United Way of Muscatine and Community Action of Eastern Iowa are partnering to provide students with winter coats through the Coats for Kids Program. School-aged children in the Muscatine, Wilton, and L&M school districts grades K-12 may be eligible to receive a winter coat at no cost. Residency restrictions apply. If your children need a coat and they attend the Muscatine, Wilton, or L&M school district, please complete the form below or call 563-324-3236 for more details.

Community Action of Eastern Iowa does not provide this service in any other area, but we would be glad to refer you to someone who does provide the service.

Winter Coat Application

What School District Do Your Children Attend? *

Muscatine

L&M

Wilton

Other

What Is Your Address?

Street Address *

Street Address

Street Address

Street Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

How many people live in your household? *

Head of Household

If homeless, check here

Homeless

Your Full Name *

Your Email Address *

Phone number where we can reach you: *

Date of Birth *

Household Member 2

Full Name *

Relation to Head of Household *

Date of Birth *

If a child in grades K-12, what size coat does the child wear? *

Household Member 3

Full Name *

Relation to Head of Household *

Date of Birth *

If a child in grades K-12, what size coat does the child wear? *

Household Member 4

Full Name *

Relation to Head of Household *

Date of Birth *

If a child in grades K-12, what size coat does the child wear? *

Household Member 5

Full Name *

Relation to Head of Household *

Date of Birth *

If a child in grades K-12, what size coat does the child wear? *

Household Member 6

Full Name *

Relation to Head of Household *

Date of Birth *

If a child in grades K-12, what size coat does the child wear? *

Income

Household Size	200% Poverty Limit
1	$25,520
2	$34,480
3	$43,440
4	$52,400
5	$61,360
6	$70,320

Self-Declaration of Income *

I assert my household income is at or below the amounts listed above.

Is Your Mailing Address The Same As The Address You Listed Above? *

Your Mailing Address

Your Mailing Address

Your Mailing Address

Your Mailing Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Is there anything else you would like us to know?

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 granting a release of information to allow Community Action of Eastern Iowa and The United Way of Muscatine to share information about your household and your application for the purpose of carrying out this program. *

Agree and Sign

If you are human, leave this field blank.