Goodwill of Southwestern Pennsylvania
Voucher Assistance Program Referral Form
Goodwill works to enhance the dignity and quality of life of individuals and families by strengthening
communities, eliminating barriers to opportunity, and helping people in need reach their full potential
through learning and the power of work. This mission continues to be supported through the items that
are donated to our retail stores, which fund programs to help people find and keep jobs and obtain
financial stability. The Voucher Assistance Program is our way of partnering wi
th other nonprofit
agencies to meet the needs of individuals and families in the community. The funds are limited, one-
time, and the following guidelines apply:
Vouchers can only be distributed to nonprofit social service organizations (you must include
501(c)(3) verification letter with application). Vouchers cannot be issued directly to individuals.
All requests for vouchers must be submitted using the form below.
All requests must include a description of the circumstances which prompted the need for a voucher.
Vouchers are only valid at Goodwill of Southwestern Pennsylvania stores (for store locations, visit
www.goodwillswpa.org
).
Vouchers cannot be sent directly to your clients.
Please allow 1-2 weeks for the review process, notification, and delivery of the voucher.
Referring Agency Information
Agency Contact Name (Printed):
Agency:
Phone #: Email Address:
Agency Address:
City: County: Zip Code:
Signature of Referring Agency Contact: Date:
Participant Information
Name: Number of People in Household:
Phone #:
Explanation of Need (use back of page if additional space is required):
Please send application and 501(c)(3) verification letter by fax, email, or mail to:
Welcome Center, Goodwill of Southwestern Pennsylvania
118 52
nd
Street, Pittsburgh, Pennsylvania 15201
welcome@goodwillswpa.org
1 -877-499-3526 Fax #: 412-632-1442
You may also complete the online form and upload verification at http://www.goodwillswpa.org/Voucher
#
To be completed by Goodwill staff:
For staff completion only
Notes:
All docs received
Data entered into tracker
Card activated
Amount issued:
Card #:
Approving Staff Signature:
Date:
Last updated 5.8.2019
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