Basic Needs Request Form

Head of Household - First/Last name

Address

City

State

Zip

Home Phone #:

Cell Phone #:

Email Address:

List all individuals living in your household: First/Last Name | M/F | Age | Date of Birth

I would like to receive emails about special events I would like to receive emails about special events Yes No

Ethnicity: (Please check all that apply) Ethnicity: (Please check all that apply) Caucasian Hispanic/Latino Black/African American Asian Native American Pacific Islander Other I prefer not to say

Monthly Household Income: Monthly Household Income: 0 - $972.00 $973 - $1,310.00 $1,311 - $1,987.00 $1,988 - $2,326.00 $2,327 - $2,664.00 $2,665 - $3,002.00 $3,003 - $3,341.00 $3,342 - $3,679.00 $3,680 - $4,018.00 $4,019 - $4,856.00 $4,857 - above

Current Sources of Income: Current Sources of Income: Work Child Support Unemployment Alimony SSI/SSDI Other

Family's Current Needs? (Mark all that apply) Family's Current Needs? (Mark all that apply) Food Rent/PUD Assistance Clothing Toiletries/Diapers Community Resources Life Skills Other

List Current Expenses: Rent/Mortage | PUD | Water | Garbage | Car | Cable/Internet | Other

Are You Current on ALL major expenses? Are You Current on ALL major expenses? Yes No

Are there members of the household with a disability? Are there members of the household with a disability? Yes No

How did you hear about Hand in Hand?