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1
of
7
- Contact Information
14%
Date
*
MM slash DD slash YYYY
Your Contact Information
Name
*
First
Last
Phone
Do you text?
Yes
No
I'm Not Sure
Email
Social Security Number
*
Date of Birth
*
MM slash DD slash YYYY
Current Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Emergency Contact Information
Name
Phone
Do they text?
Yes
No
I'm Not Sure
Relationship to you
Race
*
White
Hispanic
Asian
Native American
African American
Multi-Race
We do not discriminate against any race, color, ethnicity, sex, sexual orientation, or disability.
Health
Health Condition
*
Good
Fair
Poor
Do you need any medical attention?
*
Yes
No
Do you have any Mental Health problems?
*
Yes
No
Do you have any Substance Abuse problems?
*
Yes
No
Alcohol
Drugs
Alcohol & Drugs
Do you have a long-term disability?
*
Yes
No
Physical
Mental
Both Physical and Mental
Employment
Are you employed?
*
Yes
No
Actively searching for a job
How many hours per week are you working?
How long have you had your current job?
Type of job
Permanent
Temporary
Seasonal
Are you registered as a sex offender?
Yes
No
Yes, and I need to comply with the 2,000 FT rule
Tell us about your household (if applicable)
Household member 1 name
Relationship
Date of birth
MM slash DD slash YYYY
Sex
Male
Female
Race
White
Hispanic
Asian
Native American
African American
Multi-Race
Household member 2 name
Relationship
Date of birth
MM slash DD slash YYYY
Sex
Male
Female
Race
White
Hispanic
Asian
Native American
African American
Multi-Race
Household member 3 name
Relationship
Date of birth
DD slash MM slash YYYY
Sex
Male
Female
Race
White
Hispanic
Asian
Native American
African American
Multi-Race
Current Need
What services are you in need of today?
*
What is the reason you are currently seeking support?
*
Homelessness
Are you currently homeless?
*
Yes
No
Have you received help from MCHC in the past?
Yes
No
Month and year of last time you received help
If you do not remember the exact date, please estimate the month and year.
I am in need of
*
Rental Assistance
Emergency Housing
Rental Assistance
Please fill in this section only if you are applying for rental assistance
I am seeking support for
1st Month Rent / Deposit
On-going Rent
1st Month Rent / Deposit Starting on
MM slash DD slash YYYY
Ongoing Rent Starting on
MM slash DD slash YYYY
Landlord info
(Where payments will be sent)
Name
First
Last
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Plans for continued rent payment in future
Emergency Housing
Please fill in this section only if you are applying for emergency housing
I am seeking emergency housing for
Please enter the number of people that need emergency housing
For how many days?
If approved for emergency housing, what is your plan after this?
Please list any other sources of support you currently have
Do you smoke?
Yes
No
Client Release
*
I certify that the above information is true and complete. I authorize MCHC to acquire and share information with partner agencies when required to seek out additional resources.