Date *

MM

DD

YYYY

Client Intake Form *

Utility Assistance

Rent or Mortgage Assistance

Prescription Medication Assistance

Head of Household *

First Name

Last Name

Street Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Gender *

Female

Male

Transgender Female

Transgender Male

Non-Binary (non-conforming)

Unknown

Race *

American Indian or Alaskan Native

Native Hawaiian or other Pacific Islander

Asian/Asian American

Black or African American

White

Multi-Racial

Unknown

Other

Ethnicity *

Hispanic/Latinx or Spanish Origin

Not Hispanic/Latinx or Spanish Origin

Not listed

Unknown

U.S. Citizen *

Yes

No

Veteran Status *

Active Duty

Veteran

Civilian

Unknown

Marital Status *

Married

Divorced

Separated

Single

Widowed

Disabled *

Yes

No

Retired: *

Yes

No

Household Information *

Two Parent Household

Female Single Parent

Male Single Parent

Grandparent and Child

Single Person

Non-custodial Caregiver

Two Adults/No children

Other

Current Source(s) of Income for Household *

You must check all that apply and write the dollar amount in the space provided. Please indicate if you receive weekly, bi-weekly, or monthly. You must select something. Not providing all information can delay or cause your application to be denied. *If you select NO INCOME, please understand that all household members 18+ will be required to fill out a form certifying that there is 0 income coming into the household.

No Income

SNAP

Child Support

Employment

Pension/Retirement

Self Employment

Social Security

RSDI

SSI

Short-term Disability

TANF

Worker’s Comp

Unemployment

Other

Public Housing Assistance

VA Pension or Disability