HCEOC Intake Application
Applicant Information
Program:
*
Transportation
Weatherization Assistance Program (WAP)
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Street Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different from street address)
Mailing Address
Mailing Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Emergency Contact
*
First Name
Last Name
Emergency Contact Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
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Homeowner Information
Only complete this information if you live in a household you do not own (i.e. the homeowner is either your landlord or someone you live with). If you are the homeowner, skip this section.
Homeowner's Name
Homeowner's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Homeowner's Email
example@example.com
Homeowner's Phone Number
Please enter a valid phone number.
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Household Information
Number of people currently in your household
*
Please Select
1
2
3
4
5
6
7
8 or more
Primary language spoken in household
*
Describe your current housing situation
*
I own my home
I rent my home
I am unhoused/homeless
I live in public housing
I live in subsidized housing
Other
Describe your current household type
*
Single Person
Single Parent (male)
Single Parent (female)
2-Parent Household
Multigenerational
Non-Related Adults with Children
Other
List all sources of your household's monthly income. If no one in your household has an income, put $0 for each income source.
*
Total Income Generated (for all household members)
Employment
Other Income Source
Non-Cash Benefits
Complete the demographics for all members of your household beginning with yourself.
*
First/Last Name
Social Security Number
Date of Birth (dd/mm/yyyy)
Age
Relationship
Gender
Disability
Race
Education Level
Work Status
Health Insurance
1
0-5
6-13
14-17
18-24
25-44
45-54
55-59
60-64
65-74
75+
Unknown
Male
Female
Other
Yes
No
American Indian/Alaska Native
Asian
Black/African American
White
Native Hawaiian or Pacific Islander
Other
Multiracial (2 or more)
Unknown
Grades K-8
Grades 9-12 (Non-Graduate)
High School Graduate
GED/Equivalent Diploma
Grade 12 + Some Post-Secondary
2-Year College Grad
4-Year College Grad
Graduate of Other Post-Secondary School
Other/Not Applicable
Employed Full-Time
Employed Part-Time
Migrant or Seasonal Farm Work
Unemployed (less than 6 mos.)
Unemployed (more than 6 mos.)
Unemployed (not in labor force)
Retired
Unknown
Other/Not Applicable
Yes - Insured
No - Uninsured
2
0-5
6-13
14-17
18-24
25-44
45-54
55-59
60-64
65-74
75+
Unknown
Male
Female
Other
Yes
No
American Indian/Alaska Native
Asian
Black/African American
White
Native Hawaiian or Pacific Islander
Other
Multiracial (2 or more)
Unknown
Grades K-8
Grades 9-12 (Non-Graduate)
High School Graduate
GED/Equivalent Diploma
Grade 12 + Some Post-Secondary
2-Year College Grad
4-Year College Grad
Graduate of Other Post-Secondary School
Other/Not Applicable
Employed Full-Time
Employed Part-Time
Migrant or Seasonal Farm Work
Unemployed (less than 6 mos.)
Unemployed (more than 6 mos.)
Unemployed (not in labor force)
Retired
Unknown
Other/Not Applicable
Yes - Insured
No - Uninsured
3
0-5
6-13
14-17
18-24
25-44
45-54
55-59
60-64
65-74
75+
Unknown
Male
Female
Other
Yes
No
American Indian/Alaska Native
Asian
Black/African American
White
Native Hawaiian or Pacific Islander
Other
Multiracial (2 or more)
Unknown
Grades K-8
Grades 9-12 (Non-Graduate)
High School Graduate
GED/Equivalent Diploma
Grade 12 + Some Post-Secondary
2-Year College Grad
4-Year College Grad
Graduate of Other Post-Secondary School
Other/Not Applicable
Employed Full-Time
Employed Part-Time
Migrant or Seasonal Farm Work
Unemployed (less than 6 mos.)
Unemployed (more than 6 mos.)
Unemployed (not in labor force)
Retired
Unknown
Other/Not Applicable
Yes - Insured
No - Uninsured
4
0-5
6-13
14-17
18-24
25-44
45-54
55-59
60-64
65-74
75+
Unknown
Male
Female
Other
Yes
No
American Indian/Alaska Native
Asian
Black/African American
White
Native Hawaiian or Pacific Islander
Other
Multiracial (2 or more)
Unknown
Grades K-8
Grades 9-12 (Non-Graduate)
High School Graduate
GED/Equivalent Diploma
Grade 12 + Some Post-Secondary
2-Year College Grad
4-Year College Grad
Graduate of Other Post-Secondary School
Other/Not Applicable
Employed Full-Time
Employed Part-Time
Migrant or Seasonal Farm Work
Unemployed (less than 6 mos.)
Unemployed (more than 6 mos.)
Unemployed (not in labor force)
Retired
Unknown
Other/Not Applicable
Yes - Insured
No - Uninsured
5
0-5
6-13
14-17
18-24
25-44
45-54
55-59
60-64
65-74
75+
Unknown
Male
Female
Other
Yes
No
American Indian/Alaska Native
Asian
Black/African American
White
Native Hawaiian or Pacific Islander
Other
Multiracial (2 or more)
Unknown
Grades K-8
Grades 9-12 (Non-Graduate)
High School Graduate
GED/Equivalent Diploma
Grade 12 + Some Post-Secondary
2-Year College Grad
4-Year College Grad
Graduate of Other Post-Secondary School
Other/Not Applicable
Employed Full-Time
Employed Part-Time
Migrant or Seasonal Farm Work
Unemployed (less than 6 mos.)
Unemployed (more than 6 mos.)
Unemployed (not in labor force)
Retired
Unknown
Other/Not Applicable
Yes - Insured
No - Uninsured
6
0-5
6-13
14-17
18-24
25-44
45-54
55-59
60-64
65-74
75+
Unknown
Male
Female
Other
Yes
No
American Indian/Alaska Native
Asian
Black/African American
White
Native Hawaiian or Pacific Islander
Other
Multiracial (2 or more)
Unknown
Grades K-8
Grades 9-12 (Non-Graduate)
High School Graduate
GED/Equivalent Diploma
Grade 12 + Some Post-Secondary
2-Year College Grad
4-Year College Grad
Graduate of Other Post-Secondary School
Other/Not Applicable
Employed Full-Time
Employed Part-Time
Migrant or Seasonal Farm Work
Unemployed (less than 6 mos.)
Unemployed (more than 6 mos.)
Unemployed (not in labor force)
Retired
Unknown
Other/Not Applicable
Yes - Insured
No - Uninsured
7
0-5
6-13
14-17
18-24
25-44
45-54
55-59
60-64
65-74
75+
Unknown
Male
Female
Other
Yes
No
American Indian/Alaska Native
Asian
Black/African American
White
Native Hawaiian or Pacific Islander
Other
Multiracial (2 or more)
Unknown
Grades K-8
Grades 9-12 (Non-Graduate)
High School Graduate
GED/Equivalent Diploma
Grade 12 + Some Post-Secondary
2-Year College Grad
4-Year College Grad
Graduate of Other Post-Secondary School
Other/Not Applicable
Employed Full-Time
Employed Part-Time
Migrant or Seasonal Farm Work
Unemployed (less than 6 mos.)
Unemployed (more than 6 mos.)
Unemployed (not in labor force)
Retired
Unknown
Other/Not Applicable
Yes - Insured
No - Uninsured
8
0-5
6-13
14-17
18-24
25-44
45-54
55-59
60-64
65-74
75+
Unknown
Male
Female
Other
Yes
No
American Indian/Alaska Native
Asian
Black/African American
White
Native Hawaiian or Pacific Islander
Other
Multiracial (2 or more)
Unknown
Grades K-8
Grades 9-12 (Non-Graduate)
High School Graduate
GED/Equivalent Diploma
Grade 12 + Some Post-Secondary
2-Year College Grad
4-Year College Grad
Graduate of Other Post-Secondary School
Other/Not Applicable
Employed Full-Time
Employed Part-Time
Migrant or Seasonal Farm Work
Unemployed (less than 6 mos.)
Unemployed (more than 6 mos.)
Unemployed (not in labor force)
Retired
Unknown
Other/Not Applicable
Yes - Insured
No - Uninsured
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Verification and Signature
Are you a citizen of the United States?
*
Yes
No
Do you have a mobility, visual or hearing impairment, or a disability?
*
Yes
No
Do you receive SNAP benefits?
*
Yes
No
Are you a veteran?
*
Yes
No
Are you Hispanic, Latino, or of Spanish descent?
*
Yes
No
Do you currently have health insurance?
*
Yes
No
Are you or have you been employed by HCEOC?
*
Yes
No
Upload proof of income and proof of residence for all members of your household, including yourself. Please ensure all document scans are clear and legible.
*
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By signing here, I hereby certify that the above information is correct to the best of my knowledge. I will supply any additional information that may be needed. I will allow HCEOC to verify my statements.
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