Name Date of Birth (Last) (First) (Middle initial) Address City. State Zip County Drivers Lic/ID. Home Telephone Cell Work.

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Name Date of Birth (Last) (First) (Middle initial) Address City. State Zip County Drivers Lic/ID. Home Telephone Cell Work."

Transcription

1 Christian Community Action 200 S. Mill Street, Lewisville, TX HELP Please Print Name as it appears on picture ID. Today s Date Name Date of Birth (Last) (First) (Middle initial) Address City State Zip County Drivers Lic/ID Home Telephone Cell Work Address Ethnicity Marital Status Gender Race Place of Birth Church Social Security Number Appointment Date You are not required to give your social security number in order to receive emergency food. How many temporary or permanent household members: Please list additional family members on a separate sheet of paper. Relationship Full Name SS# D.O.B. Sex Race Child s school Grade next term What is today s need? Who referred you? Have you or anyone else in your household been assisted by CCA before? Have you been assisted by another agency? Yes No Which Agency or Agencies? Next of kin or emergency contact with address and telephone number. PLEASE TURN THIS PAGE OVER AND COMPLETE THE REVERSE SIDE OF THIS PAGE. G:share/samshare/new fas forms/intake English revised feb 2012

2 Christian Community Action 200 South Mill Street Lewisville, TX HELP Read what you sign. Your services at CCA can be stopped for duplication of services. The below statement explains that seeing a caseworker doesn t guarantee that you will receive assistance. Also explained is that the forms and documents that you give to CCA belong to CCA. This statement explains that occasionally CCA needs speak to others about your case. We will not talk to anyone unless it is necessary. I understand that having an interview with a Family Assistance Coordinator (caseworker) does not guarantee assistance. I understand that all documents and forms copied and completed during this visit become the property of Christian Community Action. I understand that Christian Community Action will not be knowingly a part of any matter or transaction that is dishonest or illegal. I understand that firearms and weapons of any variety are prohibited on Christian Community Action property even if I possess a permit to carry or conceal those weapons. Christian Community Action will not report health related information without a HIPPA release form signed by you or the appropriate member of your family; however, if subpoenaed by local, state or federal law, I understand that all contents of this file will be released to the appropriate legal authority. I hereby give permission to any person, corporation, society organization, government agency, institution, hospital, or physician to release to Christian Community Action, Lewisville, Texas, information regarding the case of and Christian Community Action hereby is granted permission to release information on a limited basis to any person, corporation, society, organization, government agency, institution, hospital or physician who may be participating in the case management of this person. I understand that receiving duplicate services from CCA and another agency is not acceptable unless planned by my caseworker and me. Examples of some of these duplicate services could be financial assistance, health services, toys, school supplies/clothing or any CCA service. I understand that the above agreement and guidelines apply to any member of my family. Signature Date Caseworker or Witness In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, religion, color, national origin, sex, sexual orientation, gender identity, age or disability. (Not all prohibited bases apply to all programs). To file a complaint of discrimination, write USDA, Director, Office of Civil rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, DC or call (202) (voice and TDD). USDA is an equal opportunity provider and employer. MISSION STATEMENT In the Spirit of Jesus Christ, Christian Community Action ministers to the poor by providing comprehensive services that alleviate suffering bring hope and changes lives. G:share/:samshare/forms/new Fasforms/intake english- Revised 12/19/12

3 Income/Expense Report Name: Date: How often do you get paid? Circle one: daily weekly every 2 weeks twice monthly monthly Monthly net wages Income Monthly exact or average expenses Wages1 Gross(name) Housing Wages1 Net Electricity Wages 2 Gross (name) Gas Wages 2 Net Water Wages 3 Gross (name) Phone (maximum 70.00) Wages 3 Net Car Payment (maximum $400.00) Social Security Gasoline S.S.I. Auto Insurance Veteran s Disability Home Insurance Retirement Health Insurance Food Stamps Groceries TANF School Lunches Family School Expenses Friends Laundry Unemployment Clothing/Shoes Worker Comp. Medical Child Support Prescriptions Other Agencies Child Care Any Other Income Child Support Loans (explain purpose) Other (explain) Expenses Owed or Overdue Total Income Total Expenses s:samshare/forms/new fasforms revised 01/28/11

4 Name: Date: Please make a list of all your assets such as savings, money market accounts, and certificates of deposits, investments, retirement accounts, boats, recreation vehicles, real estate and automobiles. How many vehicles do your family own? Please list the year, color and make of all vehicles: Vehicle one Vehicle two Vehicle three If you do not own a vehicle, how did you get here today? What was the crisis event that caused you to seek assistance? List three people who know you and can contact you if we cannot reach you. Please give a daytime telephone number for those 3 people. If we are unable to leave you a message, we may not be able to assist you. Name Phone Name Phone Name Phone s:samshare/forms/new fasforms revised 01/28/11

5 BACKGROUND PLEASE PRINT Name Date 5 - YEAR HISTORY OF WHERE YOU HAVE LIVED History Address How Long / List Dates Landlord Name and Phone Current address address address 5 - YEAR EMPLOYMENT HISTORY History Where have you worked? What did you do? Dates of Employment Reason for Leaving Current SPOUSE/ROOMMATE/OTHER ADULT EMPLOYMENT HISTORY History Where have you worked? What did you do? Dates of Employment Reason for Leaving Current Is anyone else working in your household? PLEASE TURN THIS PAGE OVER AND COMPLETE THE REVERSE SIDE OF THIS PAGE. 200 South Mill Street Lewisville, Texas VOICE (972) 436 help FAX (972) WEB

6 BACKGROUND PLEASE PRINT Name Date In order to determine how we can be of assistance to you with all the services available, we ask you to complete the following sections. MARITAL HISTORY: Married Single Divorced Widowed If married, how many times have you been married? If divorced or widowed, how long? DRUG/ALCOHOL HISTORY: Are you concerned that anyone in your household is abusing drugs or alcohol? Does anyone in your household wish to pursue drug/alcohol addiction counseling or treatment? LEGAL HISTORY: Are there legal issues or warrants for you or anyone in your household that concern you? Is anyone on parole or probation? Does anyone in your household need legal advice? MEDICAL HISTORY: Does anyone in your household need or receive medical/psychological assistance? Does anyone have a chronic ailment? Does anyone need psychological counseling? SPIRITUAL HISTORY: Do you attend church? Are you a member? Do you need spiritual counseling or to be introduced to a local church? EDUCATION HISTORY: Grade completed-- H/H Did you attend college? Technical school? Grade completed--other Did you attend college? Technical school? Other training? Do you plan to attend college/training in the future? EMPLOYMENT ISSUES: Is anyone in your household unemployed due to a disability? Has anyone had difficulty keeping a job for more than one year at a time? Is anyone in your household presently receiving services from the Texas Rehabilitation Commission (TRC) or MHMR? G:share/samshare/forms/newfatforms/backgroundrevised South Mill Street Lewisville, Texas VOICE (972) 436 help FAX (972) WEB

7 REQUIRED DOCUMENTS FAX: PLEASE CALL HELP TO MAKE AN APPOINTMENT AND BRING IN THE FOLLOWING DOCUMENTS: Proof of current address (one these items) Current lease (landlord letter if lease does not exist) Current mortgage contract or coupon Identification on all household members (Social Security cards, if the family member has one) Driver s license State identification card School identification card Passport Social Security cards Birth certificate Documentation showing that all dependents live with you (A current lease is ideal if all are listed. If they are not listed, one document for each family member.) Current Medicaid card Report cards/current school records Immunization records Court documents Proof of all income (bring all below if you receive:) Paycheck stubs from each employed person in household Award letters from state and federal agencies as applies to your household TANF, Social Security, unemployment, food stamps Letter from employer(s) Check copies Child support Other Proof of all expenses (bring all that apply to your household) Mortgage/rent Utility bills cable, telephone, electric, gas, water Child care Auto(s) payments Auto insurance Credit card(s) Other paid receipts Documentation on any crisis (bring all that apply to your household) Doctor s letter Police/fire reports Paid receipts for unusual expenses Failure to bring required documents will delay process. It is possible that you may be required to submit more documents to show proof of a financial need during the interview. This interview does not guarantee all requested assistance. Date Signature If documents are not received by, case will be closed. If you do not return documents on time, it is possible that you will not be able to make a new appointment for up to 90 days. 200 South Mill Street Lewisville, Texas VOICE (972) 436 help FAX (972) WEB

8 Christian Community Action uses grants that have maximum income guidelines. By signing below, you are stating that the household income and address listed on this form are both correct. Date Name Zip. Family Size My estimated monthly household gross income (before taxes are deducted) is $ Signature Do not write below this line Caseworker has checked income by reviewing pay stubs, award letters or employer s letters and the actual monthly & annual gross income is as stated below. $ x 12 $ Initials of Caseworker

Iowa Department of Human Services Application for Food Assistance

Iowa Department of Human Services Application for Food Assistance What is Food Assistance? Iowa Department of Human Services Application for Food Assistance Food Assistance is a program to help buy food for good health. How Do I Get Food Assistance? Step 1. Fill out

More information

Georgia Department of Human Services Georgia Senior Supplemental Nutrition Assistance Program (SNAP) Application

Georgia Department of Human Services Georgia Senior Supplemental Nutrition Assistance Program (SNAP) Application Georgia Department of Human Services Georgia Senior Supplemental Nutrition Assistance Program (SNAP) Application This application is used for individuals applying for the Supplemental Nutrition Assistance

More information

Madsen Properties, Inc.

Madsen Properties, Inc. Madsen Properties, Inc. 27128 State Highway 78, Suite 1 Battle Lake, MN 56515 218-864-5400 1-800-728-5401 Dear Applicant, Thank you for your interest in our affordable apartments. The application you downloaded

More information

CLIENT INFORMATION OFFICE USE ONLY. TODAY'S DATE: Name: Any other names you may be known by: INFORMATION ABOUT YOU: SS#

CLIENT INFORMATION OFFICE USE ONLY. TODAY'S DATE: Name: Any other names you may be known by: INFORMATION ABOUT YOU: SS# CLIENT INFORMATION INFORMATION ABOUT YOU: TODAY'S DATE: Name: Any other names you may be known by: SS# Date of Birth Physical Address Mailing (if different) City State Phone #s Hm Cell Wk E-mail address

More information

We Do Business in Accordance to the Federal Fair Housing Law

We Do Business in Accordance to the Federal Fair Housing Law PLEASE COMPLETE IN FULL Housing Authority of the City of Fort Myers Public Housing Application SOUTHWARD VILLAGE APTS. 3040 Franklin Street, Fort Myers, FL 33916 Telephone (239) 332-6635 Fax (239) 344-3273

More information

South Carolina Medicaid Program Annual Review Form

South Carolina Medicaid Program Annual Review Form Date: BG #: HH #: Case Name: South Carolina Medicaid Program Annual Review Form This form is used to review your Medicaid coverage. You must return this form to us by: Return to: Healthy Connections, PO

More information

Application for Membership Fishers of Men Ministries

Application for Membership Fishers of Men Ministries Application for Membership Fishers of Men Ministries Date Interviewer 1. Print Name (Last, First, Middle) 2. Date of Birth,, Month Day Year 3. What is your social security number? 4. What is your driver

More information

CANCER ANGELS OF SAN DIEGO 1915 Aston Avenue, Carlsbad, CA. 92008 phone: (760) 942-6346 Fax: (760) 683-3088 website: www.cancerangelsofsandiego.

CANCER ANGELS OF SAN DIEGO 1915 Aston Avenue, Carlsbad, CA. 92008 phone: (760) 942-6346 Fax: (760) 683-3088 website: www.cancerangelsofsandiego. CANCER ANGELS OF SAN DIEGO phone: (760) 942-6346 Fax: (760) 683-3088 website: www.cancerangelsofsandiego.org CLIENT APPLICATION Candidates applying for financial assistance must have a diagnosis of Metastatic

More information

Application for Legal Assistance

Application for Legal Assistance Application for Legal Assistance 1. What kind of problem do you need help with? Divorce Child Custody Guardianship Bankruptcy Tax Landlord/Tenant Will / Estate Planning Other 2. Applicant Information Your

More information

Apply for Free and Reduced Price Meals OR Prepay for Meals Online!

Apply for Free and Reduced Price Meals OR Prepay for Meals Online! Stafford County Public Schools Apply for Free and Reduced Price Meals OR Prepay for Meals Online! Dear Parent/Guardian, Stafford County Public Schools Is pleased to announce the availability of applying

More information

Pre-Bankruptcy Filing Certification Credit Counseling DISCLOSURE AGREEMENT

Pre-Bankruptcy Filing Certification Credit Counseling DISCLOSURE AGREEMENT Pre-Bankruptcy Filing Certification Credit Counseling DISCLOSURE AGREEMENT Thank you for contacting Comprehensive Credit Counseling of Rural Services of Indiana, Inc. for you Pre- Bankruptcy Filing Certification.

More information

FREE CARE APPLICATION ATTACHMENT

FREE CARE APPLICATION ATTACHMENT FREE CARE APPLICATION ATTACHMENT PLEASE REMEMBER THIS IS NOT AN INSURANCE PLAN IT IS A CHARITABLE CARE PROGRAM AND THERE IS NO ESTABLISHED FUND. THERE IS NO MONEY EXCHANGED FOR SERVICES BY ANY CMC PHYSICIAN/PRACTICE.

More information

P E N N S Y L V A N I A

P E N N S Y L V A N I A P E N N S Y L V A N I A Application for Payment of Medicare Premiums, Coinsurance and Deductibles If you have a disability and need this form in large print or another format, please call our helpline

More information

L E T T E R T O H O U S E H O L D

L E T T E R T O H O U S E H O L D Free and Reduced Price School Meals Letter to Households Page 1 of 1 L E T T E R T O H O U S E H O L D Dear Parent/Guardian: School Year 2014 2015 * * * * * * * * * * * * * * * NEW THIS SCHOOL YEAR!!!

More information

You will need to mail or fax us copies of items that apply to your case. See the next page for a list of these items.

You will need to mail or fax us copies of items that apply to your case. See the next page for a list of these items. Getting started: Health care for children CHIP and Children s Medicaid These programs offer health-care benefits for newborns and children age 18 and younger who live in Texas. With these programs, your

More information

Senior Home Repair Program Application

Senior Home Repair Program Application Senior Home Repair Program Application HIT (Home Is The) Foundation To qualify, you must: Be age 60 or over Be a resident of Preble County Own your home Meet 50% AMI (area median income) guidelines* *(see

More information

**Keep in mind that you do not need to mail this print-out to your local application site.**

**Keep in mind that you do not need to mail this print-out to your local application site.** **Keep in mind that you do not need to mail this print-out to your local application site.** Thank you for using PEAK to apply for benefits! Uni Cycle, your application has been submitted to Boulder on

More information

There are other Medicaid programs that require a different application from this one.

There are other Medicaid programs that require a different application from this one. MEDICAID APPLICATION FOR Qualified Medicare Beneficiaries (QMB) Specified Low Income Medicare Beneficiaries (SLIMB) Qualified Individuals 1 (QI) Working Disabled Individuals (WDI) INFORMATION FOR THE APPLICANT

More information

Name Date. Address Phone. Household Size (City) (State) (Zip) How long have you lived in Louisa County? Where did you live before? How long?

Name Date. Address Phone. Household Size (City) (State) (Zip) How long have you lived in Louisa County? Where did you live before? How long? 1 LOUISA COUNTY COMMUNITY SERVICES 117 S. Main St., PO Box 294 Wapello, Iowa 52653 General Assistance Application Phone 319-523-5125 Name Date Address Phone (Street) (P.O. Box) Household Size (City) (State)

More information

Application for Benefits

Application for Benefits Application for Benefits If you need help reading or completing this form, please ask us for help. Keep this page for your records. How do I apply for benefits? To complete your application fill out pages

More information

AFFORDABLE HOUSING APPLICATION

AFFORDABLE HOUSING APPLICATION AFFORDABLE HOUSING APPLICATION PLEASE FILL OUT THIS APPLICATION COMPLETELY. ALL BLANKS MUST BE FILLED IN BEFORE THE APPLICATION W I L L B E C O N S I D E R E D C O M P L E T E A N D C A N B E PROCESSED

More information

Attention: Please read this entire page before filling out the application. If you do not provide what is needed, we cannot help you.

Attention: Please read this entire page before filling out the application. If you do not provide what is needed, we cannot help you. Attention: Please read this entire page before filling out the application. If you do not provide what is needed, we cannot help you. SCC CANNOT GIVE ANY IMMEDIATE HELP. Allow up to 3-4 weeks for processing

More information

COUNTY OF POLK Community, Family & Youth Services. Application Guidelines

COUNTY OF POLK Community, Family & Youth Services. Application Guidelines Application Guidelines In order to be eligible for you must: Reside in Polk County Be over 18 or an emancipated minor Meet income and eligibility guidelines Apply first for any state or federal programs

More information

EMERGENCY FINANCIAL ASSISTANCE APPLICATION PACKET

EMERGENCY FINANCIAL ASSISTANCE APPLICATION PACKET LAKE COUNTY VETERANS SERVICE OFFICE An Office of the Lake County Government 105 Main Street, (Lake County Administration Building), Painesville, OH 44077 (440) 350-2904 or (440) 350-2567 EMERGENCY FINANCIAL

More information

Thank you for considering a grant from Homes Are Possible, Inc. (HAPI)!

Thank you for considering a grant from Homes Are Possible, Inc. (HAPI)! Thank you for considering a grant from Homes Are Possible, Inc. (HAPI)! Home rehabilitation work may include but is not limited to: Roof repairs/shingles Siding Windows/Door Plumbing Electrical Foundation

More information

STATE OF VERMONT. Defendant Name V. FINANCIAL AFFIDAVIT (813A) Other: Street Address (if different from Street Address)

STATE OF VERMONT. Defendant Name V. FINANCIAL AFFIDAVIT (813A) Other: Street Address (if different from Street Address) STATE OF VERMONT SUPERIOR COURT Unit Plaintiff Name DOB FAMILY DIVISION Docket No. Defendant Name DOB V. FINANCIAL AFFIDAVIT (813A) I am: Plaintiff Defendant Other: Name Street Address (if different from

More information

Massachusetts Department of Transitional Assistance FOOD STAMP BENEFITS FOR YOU AND YOUR FAMILY- APPLY TODAY! IT S EASIER THAN YOU THINK!

Massachusetts Department of Transitional Assistance FOOD STAMP BENEFITS FOR YOU AND YOUR FAMILY- APPLY TODAY! IT S EASIER THAN YOU THINK! Massachusetts Department of Transitional Assistance FOOD STAMP BENEFITS FOR YOU AND YOUR FAMILY- APPLY TODAY! IT S EASIER THAN YOU THINK! HOW TO APPLY To apply for food stamp benefits, please fill out

More information

HOW TO APPLY FOR FREE AND REDUCED PRICE SCHOOL MEALS

HOW TO APPLY FOR FREE AND REDUCED PRICE SCHOOL MEALS HOW TO APPLY FOR FREE AND REDUCED PRICE SCHOOL MEALS Please use these instructions to help you fill out the application for free or reduced price school meals. You only need to submit one application per

More information

Kansas Department for Children and Families Grandparents as Caregivers Cash Assistance Application

Kansas Department for Children and Families Grandparents as Caregivers Cash Assistance Application Kansas Department for Children and amilies Grandparents as Caregivers Cash Assistance Application ollow These Steps to Apply Agency Use Only Initial Review ES-3100.9 Rev. 7-12 Complete this form or go

More information

University of Pennsylvania Health System Health Services Policy and Procedure. Effective: 3/1/15 Page: 1 of 11

University of Pennsylvania Health System Health Services Policy and Procedure. Effective: 3/1/15 Page: 1 of 11 Page: 1 of 11 Keywords Free Care Uninsured Under insured Financial counseling Financial assistance Charity Care See Also HUP #1-12-17 Non-Discrimination PPMC #02.100 Non-Discrimination PAH #CC1 Admission

More information

Long Term Care Program Medical Assistance Application

Long Term Care Program Medical Assistance Application Long Term Care Program Medical Assistance Application Instructions: This is an application for Medical Assistance that will cover some or all of the costs of persons who stay in approved Long Term Care

More information

Children s Medical Programs

Children s Medical Programs Need help completing a Children s Medical application? 1. Make sure you send in the following: Proof of U.S. citizenship or alien status only for the child(ren) in your household that are applying for

More information

TOWN OF GORHAM NEW HAMPSHIRE

TOWN OF GORHAM NEW HAMPSHIRE TOWN OF GORHAM NEW HAMPSHIRE APPLICATION FOR PUBLIC ASSISTANCE CASE # Date of Application Referred by 1. General Information: Name Date of Birth Address Telephone Social Security number US Citizen? Marital

More information

CREDIT & BUDGET COUNSELING CHECKLIST. Completed Housing Intake Forms Including Budget Sheet, Release of Information, & Privacy Statement

CREDIT & BUDGET COUNSELING CHECKLIST. Completed Housing Intake Forms Including Budget Sheet, Release of Information, & Privacy Statement CREDIT & BUDGET COUNSELING CHECKLIST PLEASE BRING EACH OF THE FOLLOWING TO YOUR APPOINTMENT: Completed Housing Intake Forms Including Budget Sheet, Release of Information, & Privacy Statement Copy of Pay

More information

Home Equity Line of Credit Application

Home Equity Line of Credit Application Applicant s Name 322 East Main Avenue Bismarck, ND 58501 (701) 250-3000 Lender Please tell us about yourself and co-applicant, if applicable Co-Applicant s Name Home Equity Line of Credit Application Home

More information

GUIDELINES FOR ACCEPTANCE IN THE HABITAT FOR HUMANITY OF PULASKI COUNTY PROGRAM

GUIDELINES FOR ACCEPTANCE IN THE HABITAT FOR HUMANITY OF PULASKI COUNTY PROGRAM GUIDELINES FOR ACCEPTANCE IN THE HABITAT FOR HUMANITY OF PULASKI COUNTY PROGRAM 6700 S. University Ave. Little Rock, AR 72209 501.376.4434 Apply for a Home 1. You will be considered for a Habitat home

More information

Lee County Central Point of Coordination Application Return Application Requested By: HIPPA Yes NO. Date of Application: / / Phone: #( )- -

Lee County Central Point of Coordination Application Return Application Requested By: HIPPA Yes NO. Date of Application: / / Phone: #( )- - Lee County Central Point of Coordination Application Return Application Requested By:_ HIPPA Yes NO Date of Application: / /Phone: #()-- Name of Applicant: Last First M.I. Current Address: City State Zip

More information

Mary Washington Healthcare 1001 Sam Perry Boulevard Fredericksburg, VA 22401 Phone (540) 741-2844 or (855) 330-4857 Fax (540) 741-4054

Mary Washington Healthcare 1001 Sam Perry Boulevard Fredericksburg, VA 22401 Phone (540) 741-2844 or (855) 330-4857 Fax (540) 741-4054 Mary Washington Healthcare Phone (540) 741-2844 or (855) 330-4857 Fax (540) 741-4054 Dear Mary Washington Healthcare patient, Thank you for choosing Mary Washington Healthcare for your healthcare needs.

More information

HARTLAND CONSOLIDATED SCHOOLS

HARTLAND CONSOLIDATED SCHOOLS HARTLAND CONSOLIDATED SCHOOLS Lisa Archey, Student Nutrition Director 10632 Hibner Rd. Telephone (810) 626 2867 Hartland, MI 48353 Fax (810) 626 2869 FREQUENTLY ASKED QUESTIONS ABOUT FREE AND REDUCED PRICE

More information

Patient Financial Assistance Program

Patient Financial Assistance Program PO Box 1810, Burlington, Vermont 05402 802-847-8000, 800-639-2719 Fax: 802-847-7618 customerservice@uvmhealth.org Dear Applicant, Thank you for choosing The University of Vermont Medical Center as your

More information

Application for Benefits

Application for Benefits Application for Benefits If you need help reading or completing this form, please ask us for help. Keep this page for your records. How do I apply for benefits? To complete your application fill out pages

More information

Free or Low-Cost Health Insurance For Families with Children and Pregnant Women

Free or Low-Cost Health Insurance For Families with Children and Pregnant Women Free or Low-Cost Health Insurance For Families with Children and Pregnant Women MaineCare (formerly Medicaid & Cub Care) Department of Health and Human Services What services are covered? If you or your

More information

South Dakota Application for Medicare Savings Program

South Dakota Application for Medicare Savings Program DSS-EA-270 10/15 South Dakota Application for Medicare Savings Program NOTE: This application CAN be used for a single person or a couple (self and spouse). If you want more information on the following

More information

Trumbull Career and Technical Center 528 Educational Highway Warren, Ohio 44483 Toll Free 1-866-737-6925

Trumbull Career and Technical Center 528 Educational Highway Warren, Ohio 44483 Toll Free 1-866-737-6925 Trumbull Career and Technical Center 528 Educational Highway Warren, Ohio 44483 Toll Free 1-866-737-6925 Dear Parent/Guardian: Children need healthy meals to learn. TCTC offers healthy meals every school

More information

9. WILL THE INFORMATION I GIVE BE CHECKED? Yes and we may also ask you to send written proof.

9. WILL THE INFORMATION I GIVE BE CHECKED? Yes and we may also ask you to send written proof. Dear Parent/Guardian: Children need healthy meals to learn. Your child s school offers healthy meals every school day. Your childr en may qualify for free meals or for reduced price meals. 1. DO I NEED

More information

Application for Request for a Tax Payment Plan and Your Responsibilities

Application for Request for a Tax Payment Plan and Your Responsibilities Application for Request for a Tax Plan and Your Responsibilities Attached you will find an application for requesting a Tax Plan from the New Durham Board of Selectmen. Please fully complete the application.

More information

CHILD CARE GRANT SPRING 2016, SUMMER 2016

CHILD CARE GRANT SPRING 2016, SUMMER 2016 1130 Women s Resource /Returning Adult Program Lansing Community College P. O. Box 40010 Lansing, Michigan 48901 7210 Phone: (517) 483 1199 Fax: (517) 483 9645 http://www.lcc.edu/wrc email: wmnrsrc@lcc.edu

More information

INITIAL CLIENT QUESTIONNAIRE Financial. Name: SSN: DOB: Spouse: SSN: DOB: Address: City: State: Zip: Length of Residence:

INITIAL CLIENT QUESTIONNAIRE Financial. Name: SSN: DOB: Spouse: SSN: DOB: Address: City: State: Zip: Length of Residence: FOR OFFICE USE ONLY Chapter 7 13 Individual Joint Attorney s Fee: Filing Fee: INITIAL CLIENT QUESTIONNAIRE Financial Date: Name: SSN: DOB: Spouse: SSN: DOB: Address: City: State: Zip: County: Length of

More information

DO I QUALIFY? To qualify for assistance from Ribbon Riders, you must meet the following criteria:

DO I QUALIFY? To qualify for assistance from Ribbon Riders, you must meet the following criteria: Ribbon Riders, Inc. PO Box 952283 Lake Mary, FL 32795 407.796.7465 Thank you for contacting Ribbon Riders regarding our Breast Cancer Assistance program. Please review the attached information prior to

More information

BUSINESS MICROLOAN APPLICATION. Quin Rivers, Inc.

BUSINESS MICROLOAN APPLICATION. Quin Rivers, Inc. BUSINESS MICROLOAN APPLICATION Quin Rivers, Inc. 12025 Courthouse Circle, New Kent, VA 23124-0208 Tel: (804) 966-8752 Fax: (804) 966-8739 Thank you for contacting Quin Rivers for a business loan. The basic

More information

NOTICE OF DIRECT CERTIFICATION

NOTICE OF DIRECT CERTIFICATION East Catholic School 2001 Ardmore Blvd. Pittsburgh, PA 15221 Phone: 412/351-5403 Fax: 412/273-9114 www.eastcatholicschool.org Dear Parent/Guardian: Children need healthy meals to learn. East Catholic School

More information

Health Benefits for Workers with Disabilities Application

Health Benefits for Workers with Disabilities Application Illinois Department of Public Aid Health Benefits for Workers with Disabilities Application Note: This is NOT an application for cash assistance, food stamps or enrollment in the Medicaid spenddown program.

More information

3. You can complete this form to apply for our help. To submit this paper application you can:

3. You can complete this form to apply for our help. To submit this paper application you can: Montana Legal Services Association Application for Assistance HOW TO APPLY FOR HELP: 1. You can call MLSA s HelpLine at: 1-800-666-6899 The HelpLine is answered Monday Friday from 7:30 am to 6:00 pm. Sometimes

More information

Debtor s Full Legal Name: Spouse s Full Legal Name: Other Names Ever Used: Email: Tel#: Cell#: Emergency Contact (name & number):

Debtor s Full Legal Name: Spouse s Full Legal Name: Other Names Ever Used: Email: Tel#: Cell#: Emergency Contact (name & number): Law Office of Jeffrey B. Kelly, P.C. Chapter 7 Chapter 13 Bankruptcy Questionnaire DEBTOR INFO: How did you first hear about my office? Office Location Debtor s Full Legal Name: SS# DOB: Spouse s Full

More information

International Baccalaureate World Schools

International Baccalaureate World Schools California Department of Education School Nutrition Programs Nutrition Services Division Pricing Letter to Household (REV. 6/2015) International Baccalaureate World Schools Primary Years, Middle Years,

More information

Carroll College Matched Education Savings Account Application

Carroll College Matched Education Savings Account Application PERSONAL INFORMATION Name: Social Sec. No. (last four digits): Gender: Female Male Date of Birth: / / Ethnicity: African American Caucasian Latino or Hispanic Asian, Pacific Islander Native American Other

More information

EXPERIMENT IN SELF-RELIANCE, INC. 1550 University Court PO BOX 135 WINSTON-SALEM, NC 27101

EXPERIMENT IN SELF-RELIANCE, INC. 1550 University Court PO BOX 135 WINSTON-SALEM, NC 27101 EXPERIMENT IN SELF-RELIANCE, INC. 1550 University Court PO BOX 135 WINSTON-SALEM, NC 27101 Dear Applicant, We are pleased and excited that you have inquired about the New Century IDA home ownership program.

More information

CRIME VICTIM COMPENSATION APPLICATION

CRIME VICTIM COMPENSATION APPLICATION CRIME VICTIM COMPENSATION APPLICATION Michigan Department of Community Health For Office Use Only: Claim Number: Cross Reference Number: AUTHORITY: PA 223 of 1976 COMPLETION: Is Voluntary, but is required

More information

HURRICANE IKE INTAKE APPLICATION

HURRICANE IKE INTAKE APPLICATION HURRICANE IKE INTAKE APPLICATION INSTRUCTIONS FOR APPLICATION STEP 1: Read the instructions for this application and the Frequently Asked Questions (FAQ). They contain important information about documents

More information

Individuals wanting to purchase a car through this program must meet the following qualifications:

Individuals wanting to purchase a car through this program must meet the following qualifications: Tier II Program Individuals wanting to purchase a car through this program must meet the following qualifications: You must have a verifiable job offer or be working at least 30 hours a week. If enrolled

More information

Sample Only. Grant & Aid Application For the School Year Beginning Fall 2012. Save Time Apply Online. Information needed to complete your application:

Sample Only. Grant & Aid Application For the School Year Beginning Fall 2012. Save Time Apply Online. Information needed to complete your application: 10000028406 Save Time Apply Online. Apply online at www.factstuitionaid.com - Applying online is the fastest and most direct method of submitting your application. It allows your institution to view your

More information

Personal Information. 6 Social Security Number: 7 Driver s License Number: Class / Number / State

Personal Information. 6 Social Security Number: 7 Driver s License Number: Class / Number / State Town of Sheffield Sheffield, Massachusetts 01257 Employment Application The Town of Sheffield is an Equal Opportunity Employer All information must by typed or printed in readable writing. Unreadable applications

More information

Board of County Commissioners, Broward County, Florida HUMAN SERVICES DEPARTMENT FAMILY SUCCESS ADMINISTRATION DIVISION

Board of County Commissioners, Broward County, Florida HUMAN SERVICES DEPARTMENT FAMILY SUCCESS ADMINISTRATION DIVISION Board of County Commissioners, Broward County, Florida HUMAN SERVICES DEPARTMENT FAMILY SUCCESS ADMINISTRATION DIVISION BROWARD COUNTY COMMUNITY ACTION AGENCY 2015 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM

More information

West Virginia Department of Health and Human Resources. Application for Child Care Services

West Virginia Department of Health and Human Resources. Application for Child Care Services West Virginia Department of Health and Human Resources Application for Child Care Services I. INSTRUCTIONS Please complete this form in order to apply for child care services. Be sure to sign and date

More information

Georgia Lions Lighthouse Foundation Better vision. Better hearing. Better Georgia.

Georgia Lions Lighthouse Foundation Better vision. Better hearing. Better Georgia. Georgia Lions Lighthouse Foundation Better vision. Better hearing. Better Georgia. Thank you for contacting the Georgia Lions Lighthouse Foundation Hearing Program for hearing aid assistance. The Lighthouse

More information

LOAN APPLICATION PACKAGE Please take a moment to review these instructions for completing this application.

LOAN APPLICATION PACKAGE Please take a moment to review these instructions for completing this application. LOAN APPLICATION PACKAGE Please take a moment to review these instructions for completing this application. To ensure that your loan will be processed in a timely manner, be sure to submit all the required

More information

NEW JERSEY HOME ENERGY PROGRAMS. Home Energy Assistance Universal Service Fund Weatherization Assistance

NEW JERSEY HOME ENERGY PROGRAMS. Home Energy Assistance Universal Service Fund Weatherization Assistance NEW JERSEY HOME ENERGY PROGRAMS Home Energy Assistance Universal Service Fund Weatherization Assistance Home Energy Assistance (HEA)/Universal Service Fund (USF) and Weatherization Application Home Energy

More information

Application Information for Children s Health Insurance Program (CHIP), Children s Medicaid, and CHIP perinatal coverage

Application Information for Children s Health Insurance Program (CHIP), Children s Medicaid, and CHIP perinatal coverage Application Information for Children s Health Insurance Program (CHIP), Children s Medicaid, and CHIP perinatal coverage CHIP CHIP covers children from birth through age 18 who do not qualify for Medicaid

More information

FAMILY ASSETS FOR INDEPENDENCE IN MINNESOTA (FAIM) FAIM New Participant Application Form AGENCY USE ONLY : Agency Name:

FAMILY ASSETS FOR INDEPENDENCE IN MINNESOTA (FAIM) FAIM New Participant Application Form AGENCY USE ONLY : Agency Name: FAMILY ASSETS FOR INDEPENDENCE IN MINNESOTA (FAIM) AGENCY USE ONLY : FAIM New Participant Application Form Revised 05/23/14 Agency Name: Bank Account Number of 1 st Deposit Asset Grant First Name MI Last

More information

MILFORD EXEMPTED VILLAGE SCHOOL DISTRICT Nutrition Services 777 Garfield Avenue Milford, OH 45150 (513) 831-5030

MILFORD EXEMPTED VILLAGE SCHOOL DISTRICT Nutrition Services 777 Garfield Avenue Milford, OH 45150 (513) 831-5030 MILFORD EXEMPTED VILLAGE SCHOOL DISTRICT Nutrition Services 777 Garfield Avenue Milford, OH 45150 (513) 831-5030 **NOW AVAILABLE** ONLINE FREE AND REDUCED APPLICATIONS FOR MILFORD EXEMPTED VILLAGE SCHOOLS

More information

Legal Name: All other names you have used in the last 6 years: Address, City, State, Zip: Mailing Address if different:

Legal Name: All other names you have used in the last 6 years: Address, City, State, Zip: Mailing Address if different: BANKRUPTCY INTERVIEW INSTRUCTIONS: The interview sheet contains basic information needed for your bankruptcy. Do the best to complete the information. If you do not know the answer, then write "I do not

More information

PRE-PURCHASE HOMEOWNERSHIP PLANNING PROCESS

PRE-PURCHASE HOMEOWNERSHIP PLANNING PROCESS Helping Overcome Poverty s Existence, Inc. P.O. Box 743 Wytheville, Va. 24382; (276) 228-6280, Fax (276) 228-0508 Toll Free Phone: 1-877-818-8680 PRE-PURCHASE HOMEOWNERSHIP PLANNING PROCESS STEP 1 - Complete

More information

Foreclosure Intervention Client Counseling Session Packet

Foreclosure Intervention Client Counseling Session Packet Foreclosure Intervention Client Counseling Session Packet IMPORTANT CLIENT NOTICE All Clients must complete all pages in this packet and provide all requested documents before an appointment can be scheduled.

More information

First Time Homebuyer Program Application Package

First Time Homebuyer Program Application Package First Time Homebuyer Program Application Package Program Services The Homeownership Program's objective is to assist in all aspects of homeownership. Services provided by our home ownership counseling

More information

Documentation Needed for Rehabilitation Program:

Documentation Needed for Rehabilitation Program: Documentation Needed for Rehabilitation Program: 1. Completed and Signed Home Rehabilitation Application (7 pages) 2. 2 Current Tax Returns (must sign 2 nd page), for everyone over 18 in household with

More information

SAMPLE ONLY. FACTS Grant & Aid Application For the School Year Beginning Fall 2015. Save Time Apply Online.

SAMPLE ONLY. FACTS Grant & Aid Application For the School Year Beginning Fall 2015. Save Time Apply Online. 10000028406 Save Time Apply Online. Apply online at online.factsmgt.com/aid w available in Spanish. Applying online allows your institution to view your application electronically within minutes of submission.

More information

Are you eligible for an ACCION Chicago small business loan?

Are you eligible for an ACCION Chicago small business loan? Lending. Supporting. Inspiring. Are you eligible for an ACCION Chicago small business loan? Y/ N Are you looking for a loan between 200 and 15,000 for your start-up business (less than 6 months of revenue

More information

Your Texas Benefits: Getting Started

Your Texas Benefits: Getting Started Your Texas Benefits: Getting Started SNAP Food Benefits (This used to be called Food Stamps.) Helps buy food for good health. Some people might get help the next work day. TANF Cash Help for Families TANF:

More information

ONLY. FACTS Grant & Aid Application For the School Year Beginning Fall 2014. Save Time Apply Online.

ONLY. FACTS Grant & Aid Application For the School Year Beginning Fall 2014. Save Time Apply Online. 10000028406 Save Time Apply Online. Apply online at online.factsmgt.com/aid w available in Spanish. Applying online allows your institution to view your application electronically within minutes of submission.

More information

PREQUALIFICATIONS RESULTS OF THE PREQUALIFICATION ARE UNOFFICIAL AND MAY CHANGE WHEN ALL ESTIMATED INFORMATION IS VERIFIED.

PREQUALIFICATIONS RESULTS OF THE PREQUALIFICATION ARE UNOFFICIAL AND MAY CHANGE WHEN ALL ESTIMATED INFORMATION IS VERIFIED. CENTRAL APPALACHIA EMPOWERMENT ZONE OF WEST VIRGINIA P.O. Box 176 Phone: 304/587-2034 Fax: 304/587-2027 PREQUALIFICATIONS The Prequalification process gives the Central Appalachia Empowerment Zone of WV

More information

What is your racial origin? (check all that apply) White Black or African Descent

What is your racial origin? (check all that apply) White Black or African Descent W-1QMB (Rev. 4/10) State of Connecticut Department of Social Services Medicare Savings Programs Application/Redetermination (QMB, SLMB, ALMB) Do you need a reasonable accommodation or special help to complete

More information

IDAHO CHILD CARE PROGRAM (ICCP)

IDAHO CHILD CARE PROGRAM (ICCP) IDAHO CHILD CARE PROGRAM (ICCP) Dear Customer, In order to process your application for Child Care Assistance in the most efficient and timely manner possible, we will need to verify certain items. We

More information

400 RUSSEL COURT, P.O. BOX 885 WOODSTOCK, IL 60098 (815) 338-5757 FAX:

400 RUSSEL COURT, P.O. BOX 885 WOODSTOCK, IL 60098 (815) 338-5757 FAX: Today s Date: APPLICANT Consumer Credit Counseling of McHenry County 400 RUSSEL COURT, P.O. BOX 885 WOODSTOCK, IL 60098 (815) 338-5757 FAX: (815) 338-9646 www.illinoiscccs.org Name: Address: City/State/Zip:

More information

Application for Vocational Rehabilitation Services

Application for Vocational Rehabilitation Services Strong Families Make a Strong Kansas Application for Vocational Rehabilitation Services Is Vocational Rehabilitation the right program for you? Some brief information about the Vocational Rehabilitation

More information

M. Caroline Cantrell & Associates, PC Attorney at Law

M. Caroline Cantrell & Associates, PC Attorney at Law M. Caroline Cantrell & Associates, PC Attorney at Law 8800 SE Sunnyside Road, Suite 207N, Clackamas, OR 97015 (503) 236-9211 549 NW 2nd Avenue, Canby Oregon 97013 (503) 266-0382 Date: PENDING FORECLOSURE,

More information

There is NO fee for mortgage assistance counseling.

There is NO fee for mortgage assistance counseling. Supporting Document Checklist Mortgage Assistance Counseling NOTE: If you have an impairment, disability, language barrier, or otherwise require an alternative means of completing this form or accessing

More information

UPMC Financial Assistance Application Information

UPMC Financial Assistance Application Information UPMC Financial Assistance Application Information UPMC offers financial assistance for medical care provided by UPMC facilities and UPMC affiliated physicians to eligible individuals and families. Based

More information

Our Mission. Promoting Independence by Providing Car Care

Our Mission. Promoting Independence by Providing Car Care Check List Douglas County Residents Only Our Mission Promoting Independence by Providing Car Care Please Submit the Following: FOR ALL APPLICANTS Fill out application completely and sign Sign the attached

More information

5. If approved, the checks will only be written directly to a provider (i.e., landlord, utility company, etc.).

5. If approved, the checks will only be written directly to a provider (i.e., landlord, utility company, etc.). Gateway Church Community Care Financial Assistance Guidelines Our primary mission is to maintain housing for Gateway regulars in connected community with others who are currently experiencing severe financial

More information

Key Real Estate Advisors, Inc.

Key Real Estate Advisors, Inc. 10231 Metro Pkwy, Suite 2 Fort Myers, Florida 33966 Office (239) 454-3749 Fax: (239) 425-0701 www.keyrealestateadvisors.com AGENT - APPLICATION CHECK LIST LEASING AGENT: Name: Phone: Email: Property Address:

More information

The McGregor Clinic Inc. Patient Registration/Demographic Form. Patient Enrollment PLEASE USE LEGAL NAME

The McGregor Clinic Inc. Patient Registration/Demographic Form. Patient Enrollment PLEASE USE LEGAL NAME The McGregor Clinic Inc. Patient Registration/Demographic Form Patient Enrollment PLEASE USE LEGAL NAME First Name: MI: Last Name: of Birth: Sex: SS#: Marital Status: Single Married Separated Divorced

More information

Where do you live? (Number and Street) Apt. # City State Zip Code

Where do you live? (Number and Street) Apt. # City State Zip Code MARYLAND DEPARTMENT OF HUMAN RESOURCES FAMILY INVESTMENT ADMINISTRATION APPLICATION FOR ASSISTANCE Your Name (Last, First, Middle) Home Telephone Work Telephone Received (Agency use only) Where do you

More information

WSSS Policy on Tuition Assistance. Procedure

WSSS Policy on Tuition Assistance. Procedure WSSS Policy on Tuition Assistance Each family, regardless of its financial situation, is an important part of the Waldorf School of Saratoga Springs. Families who feel unable to pay full tuition are invited

More information

APPLICATION FOR TELEPHONE SERVICE

APPLICATION FOR TELEPHONE SERVICE APPLICATION FOR TELEPHONE SERVICE Attached is the application for new telephone service. It is extremely important that the application be filled out completely. Incomplete applications will be returned

More information

INFORMATION ABOUT YOU

INFORMATION ABOUT YOU NOTE: With this type of form, to be completed by the client you would want the top portion to approximate your letterhead in case someone picked up this form for another to complete or some other reason

More information

Application for Mississippi Medicaid Aged, Blind and Disabled Medicaid Programs

Application for Mississippi Medicaid Aged, Blind and Disabled Medicaid Programs Application for Mississippi Medicaid Aged, Blind and Disabled Medicaid Programs This application is used for an individual, couple or child to apply for Medicaid due to age or disability. Please read each

More information

HENRY COUNTY GENERAL ASSISTANCE APPLICATION 106 N. Jackson, Mt. Pleasant, IA 52641 319-385-0790 Fax: 319-385-8016

HENRY COUNTY GENERAL ASSISTANCE APPLICATION 106 N. Jackson, Mt. Pleasant, IA 52641 319-385-0790 Fax: 319-385-8016 Appointment: HENRY COUNTY GENERAL ASSISTANCE APPLICATION 106 N. Jackson, Mt. Pleasant, IA 52641 319-385-0790 Fax: 319-385-8016 Date: Name: Phone: Current Address: From: / / to / / (street) (city) (state)

More information

Massachusetts Department of Transitional Assistance FOOD STAMP BENEFITS FOR YOU AND YOUR FAMILY- APPLY TODAY! IT S EASIER THAN YOU THINK!

Massachusetts Department of Transitional Assistance FOOD STAMP BENEFITS FOR YOU AND YOUR FAMILY- APPLY TODAY! IT S EASIER THAN YOU THINK! Massachusetts Department of Transitional Assistance FOOD STAMP BENEFITS FOR YOU AND YOUR FAMILY- APPLY TODAY! IT S EASIER THAN YOU THINK! HOW TO APPLY To apply for food stamp benefits, please fill out

More information

PALM LAKE VILLAGE. Application Fee is $25.00 Please make money order/cashier check payable to P.L.V.H.C.

PALM LAKE VILLAGE. Application Fee is $25.00 Please make money order/cashier check payable to P.L.V.H.C. PALM LAKE VILLAGE 1515 County Road One Dunedin, Florida 34698 (727) 733-8880 Monday through Friday 8:00 am to 5:00 pm (Office closed last Friday of each month for in-service day) Application Fee is $25.00

More information

Resources for Independent Living TRUE Program Eligibility Requirements

Resources for Independent Living TRUE Program Eligibility Requirements Household Size Minimum Annual Income Maximum Annual Income Resources for Independent Living TRUE Program Eligibility Requirements Applicants for the TRUE Energy Assistance must meet all of the following

More information