ASSISTANCE APPLICATION FORM 2023

WAXAHACHIE CARE SERVICES APPLICATION FORM 2023
NAME*
What type of assistance are you requesting? NO RENTAL FUNDS AVAILABLE AT THIS TIME, PLEASE DO NOT FILL OUT AN APPLICATION FOR RENT. (drive through pantry, home delivery to seniors, utility assistance, medical assistance, and other utility assistance or other) INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED. All other applications take 3-5 business days to process. *
DATE OF BIRTH*

MonthDayYear
Date
PHONE*
ADDRESS*
CITY*
STATE*
ZIP CODE*
APARTMENT COMPLEX NAME*
EMAIL ADDRESS*
example@example.com
EMERGENCY CONTACT INFORMATION*
Name, phone number, relation to you
Please check which option you are seeking assistance for:

Food Pantry ServiceMedical AssistanceATMOS Natural Gas Residential AssistanceReliant EnergyTXU EnergyOther
EMPLOYER*
CITY OF EMPLOYER*
EMPLOYMENT STATUS:
EMPLOYMENT STATUS:*

FULL TIMEPART TIMEUNEMPLOYEDSTUDENT
WHAT IS YOUR HIGHEST EDUCATION*
ETHNICITY*
GENDER*
DO YOU RECEIVE THE FOLLOWING?*

SNAPMEDICAIDMEDICARESOCIAL SECURITYSSIRETIREMENTPENSIONVETERANSWICUNEMPLOYMENTCHILD SUPPORTOTHERNONE
IF UNEMPLOYED, HOW LONG:*
DO YOU CONSIDER YOURSELF TO BE ONE OF THE FOLLOWING?*

DISABLEDVETERANRETIREDHOMELESSAT RISK OF BECOMING HOMELESSOther
Please give an explanation of your need?*
MARITAL STATUS*

MARRIEDSINGLEDIVORCEDSEPARATEDLIVE INWIDOW/WIDOWERNOT MARRIED
SPOUSE INFORMATION

If married, all fields must be answered. IF NOT MARRIED, FILL SPACE WITH N/A
SPOUSE NAME:*
SPOUSE DATE OF BIRTH

MonthDayYear
Date
SPOUSE EMAIL ADDRESS*
example@example.com
SPOUSE EMPLOYER*
SPOUSE CITY OF EMPLOYER*
SPOUSE EMPLOYMENT STATUS:*

FULL TIMEPART TIMEUNEMPLOYEDSTUDENTOther
SPOUSE HIGHEST EDUCATION*
SPOUSE ETHNICITY*
SPOUSE GENDER*
DOES YOUR SPOUSE RECEIVE THE FOLLOWING?*

SNAPMEDICAIDMEDICARESOCIAL SECURITYSSIRETIREMENTPENSIONVETERANSWICUNEMPLOYMENTCHILD SUPPORTOTHERNONE
IF SPOUSE IS UNEMPLOYED, FOR HOW LONG:*
IS YOUR SPOUSE CONSIDERED TO BE ONE OF THE FOLLOWING?*

DISABLEDVETERANRETIREDHOMELESSAT RISK OF BECOMING HOMELESSOther
OTHER FAMILY MEMBERS
PLEASE LIST ALL ADDITIONAL HOUSEHOLD MEMBERS

*All fields must be answered, use N/A if not applicable*
1. NAME, DOB, RELATION, GENDER*
2. NAME, DOB, RELATION, GENDER*
3. NAME, DOB, RELATION, GENDER*
4. NAME, DOB, RELATION, GENDER*
5. NAME, DOB, RELATION, GENDER*
6. NAME, DOB, RELATION, GENDER*
GROSS MONTHLY INCOME $

ALL fields must be answered to submit. Use N/A if not applicable
Earned Applicant*
Earned Spouse*
SS Income*
SS Income Spouse*
Disability SSI#1*
Disability SSI #2*
Disability SSI #3*
Disability child*
Worker's Comp*
Unemployment*
VA Benefits*
Retirement*
Pension*
SNAP*
TANF*
WIC*
Child Support*
Family Support*
Rental Income*
Assets owned*
Sale of Property*
Sale of Property Year*
Other Income*
WAXAHACHIE CARE IS AN EQUAL OPPORTUNITY PROVIDER

Waxahachie CARE Services does not and shall not discriminate on the basis of race, color, religion, gender, gender expression, age, national origin, disability, marital status, sexual orientation, or military status, in any of its activities or operations.
ALL INCOME MUST BE PROVIDED AND MAY BE VERIFIED. IF INCOME IS LATER FOUND THAT IS NOT DISCLOSED, BENEFITS MAY BE SUSPENDED OR DENIED. HANDWRITTEN PROOF OF INCOME WILL NOT BE ACCEPTED! BANK STATEMENTS THAT SHOW WHO AND WHERE DEPOSITS ARE FROM WILL BE ACCEPTED AS LONG AS NAME AND ADDRESS MATCH.

Please read: I confirm that the information provided is complete and correct to the best of my knowledge. I am also aware that any attempt to obtain aid fraudulently from Waxahachie CARE Services will result in my application being denied and services suspended. I understand that any and all information supplied by me on this form may be verified. Tax Return may be requested to verify income. I give my permission to Waxahachie CARE Services to share information with other agencies and utilities, if necessary. We do not pay/pledge first and last month on utility or rent.

This application does not guarantee any form of payment, pledge or responsibility from Waxahachie CARE Services. Incomplete applications will not be considered.
I also agree to allow Waxahachie CARE Services to perform the following actions:
1. Use my demographic information in monthly statistical reports, county and city reports.
2. Contact past and present employers to verify my employment status.
3. Contact my apartment manager/landlord, utility providers or any other contact to verify my situation.
4. Contact other social service agencies on my behalf to network my efforts in receiving assistance.
DATE*

MonthDayYear
Date
SIGNATURE*

Clear
Waxahachie CARE - Required Information & Service Areas

Our purpose is to help those in need only.

Items needed to receive service - no exceptions. Submit documents and photos below.

1. Photo ID or driver's license

2. Proof of residency; Lease/rental agreement or tax record

3. Proof of income for everyone in the household

HANDWRITTEN PROOF OF INCOME WILL NOT BE ACCEPTED! BANK STATEMENTS THAT SHOW WHO AND WHERE DEPOSITS ARE FROM WILL BE ACCEPTED AS LONG AS NAME AND ADDRESS MATCH.
1. Earned Income - 1 month of check stubs
2. Social Security income
3. Disability income
4. Worker's Compensation
5. Unemployment/TWC Work History
6. VA benefits
7. Retirement
8. Pension
9. SNAP (Food Stamps) approval or denial
10. TANF (temporary assistance for needy families)
11. WIC (Women, Infant, Children)
12. Child Support
13. Family Support
4. Names and DOB of everyone in the household

5. Proof of medical information or bills
Photo ID or driver's license*

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multiple files can be uploaded
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Proof of residency; lease/rental agreement or tax record*

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multiple files can be uploaded
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Proof of income for everyone in the household. HANDWRITTEN PROOF OF INCOME WILL NOT BE ACCEPTED! BANK STATEMENTS THAT SHOW WHO AND WHERE DEPOSITS ARE FROM WILL BE ACCEPTED AS LONG AS NAME AND ADDRESS MATCH.*

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multiple files can be uploaded
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Current auto insurance card

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If you are seeking for bill pay assistance, please upload a file of the bills here.

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You can select multiple photos of bills.
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If you need assistance because of a job loss, COVID, medical condition or emergency situation, or if your unique situation needs further verification, the following will need to be provided in addition to the above requirements.

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Proof of medical information, if this is a cause for your current situation | Proof of fire or police report, if this is a cause for your current situation | Proof of actively trying to get a job for those that are able | Unemployment information, including a letter stating you are no longer working | Worker's Compensation | Current Tax return | Proof of school age children; report card or letter from school | Proof of COVID test results in the last 6 weeks from a doctors office or testing site
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If you need assistance because of a job loss, COVID, medical condition or emergency situation, or if your unique situation needs further verification, the following will need to be provided in addition to the above requirements.
1. Proof of medical information/bills, if this is a cause for your current situation
2. Proof of fire or police report, if this is a cause for your current situation
3. Proof of actively trying to get a job for those that are able
4. Unemployment information, including a letter stating you are no longer working
5. Worker's Compensation
6. Current Tax return
7. Proof of school age children; report card or letter from school
8. Proof of COVID test results from a doctors office with dates
SERVICE AREA:

PANTRY SHOPPING & TXU ELECTRIC: All of Ellis County except Midlothian & Ennis, TX

RELIANT ENERGY & ATMOS GAS: All of Ellis County

WATER: ONLY WHEN FUNDS ARE AVAILABLE

If you do not live in our service area, the following areas have a pantry for your convenience:
- Midlothian - Manna House, 3241 Robinson Road, Suite A, 972.775.1800
- Ennis - Helping Hands, 604 NE Main St., 972.875.0218
- Red Oak - North Ellis County Outreach, 404 S. Hwy 342, 972.617.7261
WAXAHACHIE CARE SERVICES BILL PAY AUTHORIZATION

I give permission for Waxahachie CARE Services to access my utility account and to utilize what is necessary to pay my utility bill.

I also give my consent that Waxahachie CARE Services may share my information, if necessary, with other agencies in order to process the needed paperwork.

Non unauthorized person will gain access to my information other than to process the payment of my bill.
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WAXAHACHIE CARE SERVICES APPLICATION FORM 2023

EMPLOYMENT STATUS:

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WAXAHACHIE CARE IS AN EQUAL OPPORTUNITY PROVIDER