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

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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