Community Services Application for Assistance (PDF)

• Before you return your printed form:
• Did you sign & date the application?
  
• Did you attach a copy of the bill you wish to be considered for payment?
• Did you enclose the name & address of your landlord (if you are applying for rental assistance)?

Fold the form over, fasten and return to the Butler County Community Health Office located in the basement of the Courthouse or attach postage and drop it in the mail. If you have questions call: 319.267.2663 or 800.873.0191