Services Application

Service Needed*
If Other, Please explain*
Services Application

Please complete all sections
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PRIMARY PHONE NUMBER*
Please enter a valid phone number.
SECONDARY PHONE NUMBER
Please enter a valid phone number.
Email
example@example.com
Date of Birth*

MonthDayYear
Date
Social Security Number*
Gender*
Head of Household*

YesNo
Age*
Date of Birth*

MonthDayYear
Date
Disabled*

YesNo
Military/Veteran*

ActiveRetiredNot Military
Housing Status*

RentHomeownerHomelessLiving with others
Household Size*
How Many Children Under 18*
Dependents Living With You*

NameRelationshipAgeIncome / BenefitsComments
Martial Status*
Education*
Source of Income*
If Employed, Please List Name of Employer, Occupation and How Long Employed
Annual Gross Household Income*
Monthly Net Income (after taxes)*

BUDGET (place 0 if not applicable)*

	AMOUNT
INCOME
RENT / MORTGAGE
UTILITIES
CAR PAYMENT / INSURANCE / GAS
CREDIT CARD PAYMENT
ENTERTAINMENT
FOOD
CHILD CARE
LAUNDRY / TOILETRIES
MEDICAL
OTHER
TOTAL

Do You Own Your home?
Do You Want To Buy A Home
Do You Own A Business*
If Yes What Type of Assistance Is Needed*
What is Your Credit Score?*
Have You Pulled Your Credit Score Within The Past Three Months: *
(request) for free at: www.annualcreditreport.com
How Did You Find Out About Our Program*
I GIVE MY CONSENT FOR THE HISTORIC EASTSIDE CDC, HOUSING COUNSELING STAFF OR REPRESENTATIVE TO CREATE A MANUAL AND ELECTRIC CLIENT MANAGEMENT / TRACKING FILE TO USE PERSONAL DATA TO AID THE ADVANCEMENT OF ITS EFFORTS TO SUSTAIN OR GAIN FUNDING TO SHARE AND RECEIVE MY PERSONAL INFORMATION AND DOCUMENTS AS IT RELATES TO MY NEED FOR SERVICE TO USE MY PERSONAL DATA AND PROFILE AS NEEDED AND OR REQUIRED BY FUNDING SOURCES.
SIGN AND DATE*

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