CSBG App - English

Enter All Household Income Sources *

	Per Month	Per Year
Employment
TANF/Work First Family Assistance
Child Support
Supplemental Security Income (SSI)
Social Security
Food Stamps
Pension
Unemployment Insurance
Other/Specify
No Income (enter 0)

CSBG Application

Other Information
Are You a Veteran *
Do You Have Health Insurance *
Are You a Farmer *
Are You Homeless *
Have You Applied For CSBG and Been Denied Within the Last 90 Days *
Have You Received Assistance From CPCA/CSBG Within the Last 24 Months *
If You Have Received Assistance From CPCA/CSBG Within the Last 24 Months, Please Explain.

0/250
Are you *

Married Single Divorced Widow(er)
Are you currently enrolled in school (if Yes, answer a - c) *

Yes No
a. If you are, what school are you attending
b. What degree/certification are you seeking
c. What is your expected completion date
Are any other individuals in your household enrolled in training *

Yes No
If so, who and what school are they attending (include Head Start and Early Head Start)

CSBG Application

Background Check
Central Piedmont Community Action, Inc does not require a submission of your criminal background for enrollment.

Do you have any issues in your past or present which may be a barrier to gaining employment?
If so, please explain

0/200

CSBG Application

Goals
Please briefly describe why you wish to be enrolled in the Community Services Block Grant (CSBG) program and how you believe you may benefit from enrollment. Also describe any goals you have for yourself or household. If you are a former participant, please tell us what you plan to do differently if you are selected for enrollment to be successful at achieving your goals. *

0/250

CSBG Application

Complete Application
Referral Agency (if applicable) / Services Requested
I hereby attest that the information I have provided on this intake form and any attachments is true and accurate to the best of my knowledge. I understand that this information is subject to verification and I realize the deliberate falsification or misrepresentation may result in the rejection of my application, and may subject me to prosecution under applicable State and Federal statues. I hereby give my consent to information contained on this form to be discussed and/or released to concerned social service agencies or other entities in order to make an accurate determination of my eligibility and complete the delivery of assistance to my household. I have been notified of my right to appeal any denial of service or assistance for which I may be eligible and the procedure for appeal. By this consent, I shall hold CPCA harmless for any liability that I may incur as a result of any disclosure made with the bounds of my consent and authorization.

This application expires in 30 days after which a new application would need to be submitted.
Today's Date *

Month Day Year
Date
Signature of Applicant *

Clear
Signature of CSBG Staff Upon Receipt

Clear
Should be Empty:

CSBG Application - Chatham/Orange/Randolph