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* indicates required information

Client Profile

First Name

M.I.

Last Name

Address

City

Zipcode

Phone

Alt Phone

Email

Gender

Date of Birth / /

Last 4 digits of
your SS No.

If you have been diagnosed with a disability indicate the type of disability.

If you have a drug or alcohol problem indicate the type of problem.

Are you pregnant or parenting a child under age of one?
No      Yes

Will you need the services of an interpreter when we meet with you?
No      Yes
If yes, what language

Emergency Contact

Name

Relationship

Phone

Household Members

List all people living in your home

Type of Assistance Requested

Indicate the assistance that you need. Maximum of 200 characters

Situation

How long have you lived at your current address?

Type of dwelling

Ownership

Disconnection Notice
If you have received a disconnection notice for a utility enter all details below

Utility Provider

Account No. Amt Past Due $

Disconnect Date

Eviction/Foreclosure Notice
If you have received an eviction or foreclosure notice enter all details below

Type of Notice

Amt Past Due $ Eviction/Foreclosure Date

Eligibility

Income
Sources of income for all members living in your household:
Include income from employment, social security, food stamps, utility checks, public assistance, SSI/SSD, pensions, disability, unemployment, alimony, child support, VA benefits, family/friends assistance or other income.

Person receiving income Income Source Gross Monthly Income Net Monthly Income
$ $
$ $
$ $
$ $
$ $
$ $
  Totals

Monthly Expenses
Report actual amounts.

Expense Monthly Payment Required Your Actual Payment
Rent $ $
Mortgage $ $
Electric $ $
Gas $ $
Water $ $
Sewage $ $
Trash $ $
Cell Phone $ $
Car Payment $ $
Credit/Loans $ $
Cable/Phone/Internet $ $
Property Tax $ $
Totals

Other Monthly Expenses
Actual amount spend monthly on additional items: please report actual amounts.

Expense Your Actual Payment
Food $
Child Care $
Medication $
Car Fuel $
Car Insurance $
Other Insurance $
Public Transportation $
Paper Products $
Personal Products $
Laundry Supplies $
Baby Supplies $
Pet Supplies $
Children's Activities $
Recreational Activities $
Total

Assistance From Catholic Charities
List all assistance that you have received from Catholic Charities in the past 12 months.
Indicate type and amount:

Assistance From Other Agencies
List all assistance that you are currently receiving or have received in the past 12 months
from any other social service agency.
Provide agency(s) name, phone number and service(s) received:

Please state how assistance from us will change your circumstances.
This statement may be used Anonymously (no personal information included)
when communicating our services and benefits to existing or potential donors.

Your application will be processed in the order received, and we will contact you by phone.

* By submitting this application, I allow Catholic Charities to process my request for service. The information provided in this application is true and accurate to the best of my knowledge. I also understand that Catholic Charities may contact utility and other service providers to verify that all information is accurate and current.