CSBG Intake Form Step 1 of 425%Personal InformationFor a copy of the application that can be downloaded and emailed or faxed to our staff click here. Para esta aplicacion en espanol haga clic aqui.Name:* First Last Primary Phone:*Email: Address:* Street Address City State / Province / Region ZIP / Postal Code Do you or anyone in your family receive Food Stamps/SNAP?YesNoIf so, how much SNAP per month?No. of People in Family:Monthly Rent or Mortgage CostFamily type (at the present time)*Single ParentTwo Parent FamilyFoster ParentsTwo Adults, no childrenSingle PersonOtherHousing Status (at the present time)*Renter: If renter, do you receive Section 8/Subsidized rent?OwnersHomeless (with roof)Homeless (without roof)Dwelling Type*Single Family HomeTownhome/CondoDuplexMobile HomeSingle room occupancyApartmentHomeless (with roof):Family Type: OtherIf homeless, have you stayed in a shelter in the past 90 days?YesNoNumber of Apartments in your building2-45-1011 or moreDo you receive any of the following services?LIHEAPHousing Choice Voucher (Section 8)Public HousingWICChildcare Co-pay AssistanceNoneSelect the types of income in the home: Full-time employment Part-time employment Unemployment benefits Child support Workers comp Social Security Pension/retirement SSI SSDI VA benefits AABDName of person who receives income: First Last Type of income:How often do they receive incomeMonthlyWeeklyBi-weekly2 times a monthAmount (before taxes)Name of person who receives income: First Last Type of income:How often do they receive incomeMonthlyWeeklyBi-weekly2 times a monthAmount (before taxes)Name of person who receives income: First Last Type of income:How often do they receive incomeMonthlyWeeklyBi-weekly2 times a monthAmount (before taxes)Name of person who receives income: First Last Type of income:How often do they receive incomeMonthlyWeeklyBi-weekly2 times a monthAmount (before taxes)If unemployed, how long/why?If no income, how do you support yourself and/or family?Family InformationPlease fill in completelyNames of Household MemberDate of BirthAgeMilitary Service?NoVeteranActive Military ServiceDisabledYesNoUnknownGenderMaleFemaleOtherHealth InsuranceMedicaidMedicareEmployment basedCHIPDirect PurchaseVA health caren/aRaceBlackHispanicWhiteAsianNative AmericanOtherHighest level of educationPre-k0-8th grade9-12th (non grad)HS diploma/GED2-4 year degreeOtherRelationship to ApplicantNames of Household MemberDate of BirthAgeMilitary Service?NoVeteranActive Military ServiceDisabledYesNoUnknownGenderMaleFemaleOtherHealth InsuranceMedicaidMedicareEmployment basedCHIPDirect PurchaseVA health caren/aRaceBlackHispanicWhiteAsianNative AmericanOtherHighest level of educationPre-k0-8th grade9-12th (non grad)HS diploma/GED2-4 year degreeOtherRelationship to ApplicantNames of Household MemberDate of BirthAgeMilitary Service?NoVeteranActive Military ServiceDisabledYesNoUnknownGenderMaleFemaleOtherHealth InsuranceMedicaidMedicareEmployment basedCHIPDirect PurchaseVA health caren/aRaceBlackHispanicWhiteAsianNative AmericanOtherHighest level of educationPre-k0-8th grade9-12th (non grad)HS diploma/GED2-4 year degreeOtherRelationship to ApplicantNames of Household MemberDate of BirthAgeMilitary Service?NoVeteranActive Military ServiceDisabledYesNoUnknownGenderMaleFemaleOtherHealth InsuranceMedicaidMedicareEmployment basedCHIPDirect PurchaseVA health caren/aRaceBlackHispanicWhiteAsianNative AmericanOtherHighest level of educationPre-k0-8th grade9-12th (non grad)HS diploma/GED2-4 year degreeOtherRelationship to ApplicantNames of Household MemberDate of BirthAgeMilitary Service?NoVeteranActive Military ServiceDisabledYesNoUnknownGenderMaleFemaleOtherHealth InsuranceMedicaidMedicareEmployment basedCHIPDirect PurchaseVA health caren/aRaceBlackHispanicWhiteAsianNative AmericanOtherHighest level of educationPre-k0-8th grade9-12th (non grad)HS diploma/GED2-4 year degreeOtherRelationship to ApplicantNames of Household MemberDate of BirthAgeMilitary Service?NoVeteranActive Military ServiceDisabledYesNoUnknownGenderMaleFemaleOtherHealth InsuranceMedicaidMedicareEmployment basedCHIPDirect PurchaseVA health caren/aRaceBlackHispanicWhiteAsianNative AmericanOtherHighest level of educationPre-k0-8th grade9-12th (non grad)HS diploma/GED2-4 year degreeOtherRelationship to ApplicantNames of Household MemberDate of BirthAgeMilitary Service?NoVeteranActive Military ServiceDisabledYesNoUnknownGenderMaleFemaleOtherHealth InsuranceMedicaidMedicareEmployment basedCHIPDirect PurchaseVA health caren/aRaceBlackHispanicWhiteAsianNative AmericanOtherHighest level of educationPre-k0-8th grade9-12th (non grad)HS diploma/GED2-4 year degreeOtherRelationship to ApplicantNames of Household MemberDate of BirthAgeMilitary Service?NoVeteranActive Military ServiceDisabledYesNoUnknownGenderMaleFemaleOtherHealth InsuranceMedicaidMedicareEmployment basedCHIPDirect PurchaseVA health caren/aRaceBlackHispanicWhiteAsianNative AmericanOtherHighest level of educationPre-k0-8th grade9-12th (non grad)HS diploma/GED2-4 year degreeOtherRelationship to ApplicantIf there are youth ages 14-18 in the home, are they in the school?YesNoAre youths workingYesNoApplication affirmation and authorization to verify informaitonApplicant's statement:I certify that the above information is an accurate and complete disclosure of the requested information. I hereby acknowledge that the information relating to determination of my eligibility requires verification and/or documentation, and by my signature, I authorize others to release such information as may be required for determination of my eligibility.Consent:* I agree to the above statements and information listed. Applicant Signature:* First Last Date:* Intake Staff Signature* First Last Date:* CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms. ***Please see our “Community Programs” Page for a complete list of items to bring to your appointment.***Additional Income Guidelines: Click here for additional information regarding income eligibility for the Community Services Block Grant.
