Financial Service Request
Caseworker Name:_________________________________
Date
*
-
Month
-
Day
Year
Date Picker Icon
Describe your emergency
*
Name
*
Prefix
First Name
Middle Name
Last Name
Suffix
Marital Status
*
Married
Single
Divorced
Widowed
Partnership
Separated
Other
Aliases
How did you hear about us?
Dept. of Social Services
Church
Friend/Neighbor
Referred by Haven
Website
Other
Preferred Phone Number
ex: (434) 222-2222
Phone Type
*
Cell
Home
Work
Other
Secondary Phone Number
ex: (434) 222-2222
Phone Type
Cell
Home
Work
Other
Email
example@example.com
Preferred Contact Method
*
Email
Phone
Text
Date of Birth
*
-
Month
-
Day
Year
mm-dd-yyyy
Gender
Male
Female
Ethnicity
American Indian/Alaskan
Asian
Black or African American
Hispanic
Multi-Racial
Native Hawaiian/Other Pacific Islander
White
Attend Church?
Yes
No
If Yes, Primary Church
Social Media Address (Facebook, Instagram, Twitter)
Residence Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of Adults in Household
*
ex: 2
Number of Children in Household
ex: 2
Household Members
Full_Name
Relationship
Date_of_Birth
Gender
Income
Member 1
Member 2
Member 3
Member 4
Member 5
Member 6
Other Assistance: Do you have a social worker or case worker? If yes, please provide full name and where located. List any items you have requested and received from this other agency.
Please check all that apply:
Disabled -- Enter Date disability began
Able to work
Veteran
Spouse/Partner living in household
*
Yes
No
Housing StatusPermanence of Living Situation
*
Own
Rent
Section 8
Live with friend or family
Rent a room from someone
Rent out a room to others
Homeless
Other
Living Arrangement
Single Mother
Single Father
Two Parent
Couple
Single
Other
Date Housing Arrangement Began
-
Month
-
Day
Year
Date
Eviction
Received Eviction Notice
Been Evicted
Enter Eviction Date
-
Month
-
Day
Year
Date
Drivers License/ID Number
*
Drivers License/ID Expiration Date
*
-
Month
-
Day
Year
Date
Employment/Income Status
Employed
Disability/SSI
Recently lost job/laid off
About to start new job
Between Jobs
Unable to work
Retired
Unwilling to work
Other
Employer Name
Date Employment Began or will Begin
-
Month
-
Day
Year
Date
Take home income per month
ex: 700
Unemployment Benefits Status
Unemployed receiving benefits
Unemployed not receiving benefits
Other
Date Employment Ended
-
Month
-
Day
Year
Date
Amount of unemployment per month
ex: 400
Further explanation of unemployment:
What is your request?
Household Items (Bag)
Household Items (Large)
Utility Assistance
Rent/Mortgage Assistance
Prescription Assistance
Vehicle Repair
Counseling Referral
Prayer
Other (describe below)
REQUEST: Describe your request
*
VERIFICATIONS: Please provide:
Proof of Emergency (if possible)
Proof of Income
Proof of Employment
Signed Consent Form
Budget Worksheet
Verification Sheet-Related Utilities/Landlord/Employers detail
Would you be willing to take budgeting classes or receive budgeting counseling if available?
Yes
No
Would you or your family benefit from counseling services?
Yes
No
Would you be willing to be a volunteer with GRACE?
Yes
No
If yes, describe any budgeting or counseling needs
GIFTS AND ABILITIES: Please describe any special abilities and talents you have that you enjoy and others like about you. (Optional)
Budget Form and Verification Information
Enter Household Income Amounts
Monthly Income
Child Support
Employment/Wage
Family Assistance
Social Security Income (SS)
Unemployment
Spousal Support
Retirement/Pension
Cash Assistance
Other Income
TOTAL HOUSEHOLD INCOME
Enter Government Assistance Income Amounts
Monthly Amount
Disability Insurance (SDI)
Disability (SSI)
Food Stamps
Other Grant
Subsidized Rent Amount
Veteran's Benefits
WIC
Medicare/Medicaid
TOTAL GOV. ASST. INCOME
Enter Monthly Expense Amounts
Monthly Amount
Cable/Internet
Car Insurance
Car Payment
Cigarettes
Credit Card Loans
Daycare
Electricity
Food (full amount incl. food stamps)
Gas (for house)
Gasoline (car)
Homeowner's Insurance
Medical Bills
Medical Insurance
Mortgage
Other
Other Utilities
Pay Child Support
Personal Care - Hair/Nails/Misc.
Phone (landline/cell)
Property Tax/Other
Rent (full amount)
Tithe
Contributions
Education
Clothing
Toiletries/Cleaning Products
Laundry
Alcohol
TOTAL EXPENSES
MONTHLY EXCESS OR DEFICIT
TOTALS
TOTAL HOUSEHOLD INCOME
TOTAL GOVERNMENT ASSISTANCE
LESS TOTAL EXPENSES
EXCESS OR DEFICIT AMOUNT
Applicant Signature: By signing this form you certify that all information is accurate and complete to the best of your ability.
*
Written Signature and Date
Signature
Depending on your request, provide verification detail below.
Company/Landlord/Other Name
Company/Landlord/Other Contact Phone
Account Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please upload a copy of your current Driver's License or ID - you must be a resident of Greene County.
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Please upload a copy of your current income source. For example, pay stub, Government assistance letter (SSI), bank statement showing deposits, etc.
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Please upload a copy of the bill you wish us assist with or a copy of your lease/rental/Mortgage agreement
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Please upload a copy of the signed GRACE Consent Form. See link to this form, download and sign, then upload here.
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