InTake-Detail-Application-Form

AOH - MORTGAGE/RENTAL & UTILITY ASSISTANCE CLIENT INTAKE/REFERRAL

BIO INFORMATION

Label

Address

City

State

Zip

Email

Phone Number

Gender:

Male Female Transgender

Head of Household

Yes No

Marital Status

Single Married/Separated Divorced Widowed

Ethnicity

If Other, Please specify

HOUSEHOLD INFORMATION

Is there anyone in the household with Special Needs or Disabled?

Yes No

Have you been a Victim of Domestic Violence?

Yes No

Are you or anyone in the household a Veteran?

Yes No

Are You Over 55?

Yes No

Are you or anyone in the household using drug(s)

Yes No

If yes, list the type of drug(s)

Do you or anyone in the household have HIV/AIDS?

Yes No

If yes, who?

Is anyone in the Household Severe Mentally ill?

Yes No

Are You Employed?

Full Time Part Time Uuemployed

Yearly/Annual Income

TYPE OF ASSISTANCE NEEDED

Select all that apply

MORTGAGE RENTAL UTILITIES RAPID HOUSING

MORTGAGE/RENTAL ASSISTANCE

Monthly Mortgage/Rental Amount

Months Late

Are you at risk of Foreclosure/Eviction?

Yes No

Foreclosure/Eviction Date:

HOUSING HISTORY

Are you at risk of homelessness?

Yes No

If yes, please describe circumstances:

LENGTH OF HOMELESSNESS

Chronically Homeless?

Yes No Not homeless at present Homeless less than one month Radio 1 At least 6 months, but less than 1 year At least 1 year, but less than 2 years 2 years or more

Client Contribution Amount

UTILITY ASSISTANCE

Check options

WATER GAS ELECTRIC

Cut Off Date

Client Contribution Amount

CHILDCARE/TUTORING ASSISTANCE

Number of Children

Number of Weeks

Cost per Week

Contribution Amount

FOOD ASSISTANCE

Are you in need of food:

Yes No

Are you receiving assistance for any of the services above from another organization?

Yes No

If yes, list the organization, services received, and time frame

FAMILY

Name (Not the Applicant)

Relationship to Applicant

Social Security Number

Gender ___________________

Date of Birth ____________________

INCOME

Is applicant currently employed, either part-time or full-time?

Yes No

If yes, where is applicant employed

Please list any financial obligations or assistance from (child support, alimony) including the amount:

Does applicant or anyone living with him/her have a source of income:

Yes No

What is the source of income? Check all that apply

Applicant Other

MARKETING

In order for us to highlight the success of our program, we need testimonials. Do you agree to have

Yes No

Please indicate whether you agree to be interviewed on camera for a testimony.

Yes No

INCOME VERIFICATION

Anchor of Hope has created partnerships and collaborates with other entities in our community who provide funding,
support, logistics, and more for our program. Several of our funding sources require verification of income for the
families and children we serve. In order to comply, each family is required to provide the following information. All
information is confidential and will only be used for funding procurement and statistical purposes.

Client Name

Family Size (Indicate the number in each of the following categories.)

Number of Adults

Number of Children

Total Annual Household Income Range (Please check the income range that best describes your annual
household income from all sources before taxes and deductions.)

APPLICANT

FOR IN OFFICE USE ONLY:

Number in
Household

Current
Household
Income

Household
Size

200% of FPL
(CSBG)

60% Income
Limit (TBRA)

STATEMENT OF NEED

UPLOAD DOCUMENTS

Picture ID(Driver’s license, State ID, or Passport for all ages 18 and older)

Social Security Cards (Everyone in the household)

Birth Certificate for all minor children under the age of18

Income Verification (Everyone 18 and older)

Rental Lease (copy of entire lease)

Mortgage Note (copy of monthly mortgage notice)

Rent Notices (copy of Eviction, Dispossessory notice, 3-day late notice letter)

Late Utility Bill(copy of past due notice, Shut-off notice, Disconnection notice

A Statement of Need for Childcare

ACCURACY OF INFORMATION STATEMENT:

By affixing my signature below, I certify that the information I provided in this application to Anchor of Hope, Inc
(AOH) in connection with all supporting documentation that I provide is true, accurate, and complete to the best of
my knowledge. I understand that any false statements or deliberate omissions in this application or any other
documents that I provide to AOH may be grounds for disqualification from this program and may be legal grounds for
prosecution.

Print Name

Date