Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone (if you do not have a working phone number please enter 000-000-0000) *

(###)

###

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Alternate number where you can be reached

(###)

###

####

Gender

Male

Female

Other

Age

0-5

6-13

14-17

18-24

25-44

45-54

55-59

60-64

65-74

75+

Housing

Own

Rent

Other Permanent Housing

Homeless

Other

Education Level

Grades 0-8

Grades 9-12/Non-Graduate

HS Graduate / Equivalency Diploma

12 Grade + Some Post-Secondary

2 or 4 Years College Graduate

Work Status:

Employed Full-Time

Employed Part-Time

Migrant Seasonal Worker

Unemployed (Short-term, 6 months or less)

Unemployed (Long-term, more than 6 months)

Unemployed (Not in labor force)

Retired

Health Insurance:

Yes

No

Health Insurance Information:

Medicaid

Medicare

State Health Insurance for Adults

State Children's Health Insurance Program

Military Health Care

Direct-Purchase

Employment Based

Ethnicity:

Hispanic, Latin, Spanish Origins

Unknown / Not Reported

Race:

American Indian or Alaska Native

Asian

Black / African-American

Native Hawaiian and Other Pacific Islander

White

Multi-Race (Any 2 or more above)

Other

Income:

Yes

No

Non-Cash Benefits (Please check all that apply):

SNAP

Housing Choice Voucher

Childcare Voucher

HUD-VASH

Permanent Supportive Housing

WIC

Affordable Care Act Subsidy

Public Housing

LIHEAP

Other

ADDITIONAL HOUSEHOLD MEMBERS - 1

First Name

Last Name

Date of Birth:

MM

DD

YYYY

Disabled:

Yes

No

Active Military:

Yes

No

Veteran:

Yes

No

ADDITIONAL HOUSEHOLD MEMBERS - 2

First Name

Last Name

Date of Birth:

MM

DD

YYYY

Disabled:

Yes

No

Active Military:

Yes

No

Veteran:

Yes

No

ADDITIONAL HOUSEHOLD MEMBERS - 3

First Name

Last Name

Date of Birth:

MM

DD

YYYY

Disabled:

Yes

No

Active Military:

Yes

No

Veteran:

Yes

No

ADDITIONAL HOUSEHOLD MEMBERS - 4

First Name

Last Name

Date of Birth:

MM

DD

YYYY

Disabled:

Yes

No

Active Military:

Yes

No

Veteran:

Yes

No

REQUESTING ASSISTANCE WITH: *

Health / Medical Services

Employment

Social Services

Food

Clothing

Finance Development

Day Care

Education

Senior Services

Community Development

Other (Please provide an explanation in the box below if you've selected 'Other')

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