Social services intake application

Colchester Town Hall

127 Norwich Avenue, Suite 204

socialservices@colchesterct.gov

www.colchesterct.gov/yss

(860) 537-7255

Head of Household Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Format: (000) 000-0000.

E-mail

example@example.com

Social Security Number

Number of adults in household (18 years and older)

Number of children in household (under 18 years)

Household Members and Income: Please list all members of the household and LIST YOURSELF FIRST (including yourself and children) and their income (This may include but is not limited to: Employment, Unemployment, Social Security, SSI/SSD, Child Support, Pensions/ Annuities, TANF, Etc.):

Rows	First and Last name	Relationship to Applicant	Date of Birth	Child's School Grade (if applicable)	Source of Income	Monthly Income
1
2
3
4
5
6

Please fill in all applicable bill amounts PER MONTH. There may be programs available to assist with these costs:

Rows	Amount
Rent/ Mortgage
Internet
Child Care
Cell phone

Do you receive SNAP benefits?

Amount you receive in SNAP benefits:

Do you receive cash assistance/ TANF benefits?

Amount you receive in cash assistance/ TANF benefits:

Do you receive WIC benefits?

Do your children receive Free/ Reduced lunch?

Do you receive Energy Assistance through TVCCA?

Do you receive Section 8 housing assistance?

Are you currently facing a shut-off notice for your Water/ Sewer?

Are you currently facing a shut-off notice for your Electric?

Are you currently facing Eviction/ Foreclosure?

How can our program assist you?

IF OTHER, PLEASE DESCRIBE:

By entering your name below, you declare that the information on this form is complete and accurate to the best of your knowledge. Please note that Social Services requires proof of residency and proof of income upon registration. Depending on the circumstances, you may also be required to provide documentation including, but not limited to: proof of eviction, shut off notices, estimates for home or car repairs, utility bill with back balance, heating bill with back balance, current lease or mortgage statements. Documentation will vary per request.

Type your name to agree to the statement above:

Social Services Intake/Application