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? Submit Application