| Your Name: * |
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| Daytime Phone Number: * |
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| Cell Phone Number: |
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| Evening Phone Number: |
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| Email Address: |
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| Marital Status: |
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| How many children do you have? * |
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| Ages of your male children: |
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| Ages of your female children: |
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| Are your children in school? |
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| Do you pay for childcare? |
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| Are you able to provide social security cards for your children and yourself? |
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| Do you receive child support? |
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| If yes, how much? |
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| How did you become homeless? |
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| Tell us about your homeless status: |
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| In what city did you become homeless? * |
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| In what county did you become homess? * |
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| In what city are you currently living? * |
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| Are you employed? * |
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| Employer Name: |
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| Is your current job temporary or permanent? * |
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| How long have you worked at your current job? |
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| How many hours a week do you work? |
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| What is your monthly salary? |
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| How often do you get paid? |
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| Are you able to provide 1 month of check subs? |
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| If you have more than one job, please tell us about any other jobs your currently hold: |
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| Do you currently have transportation? |
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| Do you have pets? |
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| Do you receive any assistance from the Department of Family and Children Services? |
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| If yes, how much do you receive monthly from the Department of Family and Children Services? |
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| Do you receive food stamps? |
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| If yes, how much do you receive monthly in food stamps? |
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| Do you receive TANF? |
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| If yes, how much do you receive monthly from TANF? |
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| Do you receive childcare assistance? |
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| If yes, how much do you receive monthly in childcare assistance? |
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| Do you receive Medicaid?: |
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| If yes, how much do you receive monthly in Medicaid? |
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| The amount currently in your savings account: |
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| Comments: |
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