Application for Assistance

SECTION 1: APPLICANT INFORMATION

First Name:

Middle Initial:

Last Name:

Date of Birth:

Social Security # (Last 4 digits):

Gender:

Street Address:

City:

State:

ZIP Code:

County:

Phone Number:

Email Address:

Best way to contact you:

Phone

Email

Text Message

Mail

SECTION 2: HOUSEHOLD INFORMATION

Total number of people living in household (including yourself):

List all household members:

Name	Relationship	Age	Employed?	Monthly Income

SECTION 3: FINANCIAL INFORMATION

Are you currently employed?

Yes, Full-time

Yes, Part-time

No

Self-employed

Your Monthly Income (before taxes):

Total Household Monthly Income:

Sources of Income (check all that apply):

Employment

Self-Employment

Social Security

SSI/Disability

Unemployment

Child Support

TANF

Other

Do you currently receive any of the following assistance? (check all that apply)

SNAP/Food Stamps

Medicaid

Housing Assistance

WIC

Energy Assistance

None

Monthly Rent/Mortgage:

Monthly Utilities (total):

SECTION 4: TYPE OF ASSISTANCE NEEDED

If requesting financial assistance, please specify amount and purpose:

Please explain your current situation and why you are seeking assistance:

Have you received assistance from our organization before?

Yes

No

If yes, when?

SECTION 5: EMERGENCY CONTACT

Name:

Relationship:

Phone Number:

Address:

SECTION 6: ADDITIONAL INFORMATION

Special circumstances we should know about (medical conditions, disabilities, veteran status, etc.):

How did you hear about our organization?

Friend/Family

Church

Social Services

Internet

Previous Client

Other