Weatherization BIF Page 1

Northeast Nebraska Community Action Partnership

NENCAP does not discriminate on the basis of sex, age, religion, race, marital or veteran status, handicap or national origin.
Basic Intake Form

Information below is provided for the household:
Number living in household*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
County*
Phone Number*
Please enter a valid phone number.
Length of Stay @ Prior Residence
Zip of Prior Residence
Household type (Check One)*

Single PersonSingle ParentTwo Adults no ChildrenTwo parent household (married)Non-Related adults with childrenMulti-Generational
Housing Status (Check one)*

Category 1 - HomelessCategory 2 - At Imminent Risk of Losing HousingCategory 3 - Homeless only under other Federal StatutesCategory 4 - Fleeing Domestic ViolenceAt Risk of HomelessnessStably Housed
Type of Residence (Check one)*

Client Owned (without Subsidy)Client Owned (with Subsidy)Rental by Client (without Subsidy)Rental by Client (with Subsidy)Staying or living with family memberStaying or living with friendHotel or motel paid for without emergency shelter voucherEmergency Shelter, incl. hotel/motel w/em. shelter voucherSafe HavenPlace not meant for habitationTransitional housing for homeless persons and youthFoster Care Home or Foster Care Group HomePermanent Housing for formerly homelessHospital or other non psychiatric medical facilitySubstance abuse treatment or detox facilityJail, Prison or juvenile detentionLong Term Care or Nursing HomePsychiatric hospital or other Psychiatric facilityResidential project/halfway house with no homeless criteriaHost Home (non-crisis)
Rental by Client (with Subsidy)

HUD-VASHSection 8GDP/TipHCV VoucherRRH SubsidyOther Subsidy
Head of Household information
Is your need for assistance due to COVID-19*

YesNo
Name*

First NameMiddle NameLast Name
Email
example@example.com
Date of Birth*

MonthDayYear
Date
Social Security Number*
Gender*

MaleFemaleMale to FemaleFemale to MaleGender Non-Conforming
Race (Check all that apply)*

AsianAmerican Indian/Alaska NativeWhiteBlack/African Americannative Hawaiian/Pacific Islander
Ethinicity*

Hispanic/LatinoNon-Hispanic/Latino
Military Information

If Applicable
Active Military*

YesNo
Veteran*

YesNo
Year Entered
Year Seperated
Branch
Discharge Status
Theater of Operation

World War IIKorean WarVietnam WarPersian GulfAfghanistanIraqi FreedomIraq-New DawnOther
Are you disabled*

YesNo
Long Term Disable

YesNo
Type of Disability

PhysicalMentalDevelopmentalChronic HealthHIV/AIDSSubstance AbuseOther
Are you currently or ever been in Foster Care*

YesNo
Are you/have you been the victim of Domestic Violence*

YesNo
When?
Currently fleeing

YesNo
Health Insurance Status*

United HealthCare (Medicaid)WellCare (Medicaid)NE TotalCare (Medicaid)MedicareSCHIPEmployer ProvidedVA/Military BenefitsPrivate Pay-Direct PurchaseState Insurance for AdultsNone/Un-InsuredOther
Education Level*

No schoolingPre K-4th grade5th - 6th grade7th - 8th grade9th grade10th grade11th grade12th gradeHigh School DiplomaGEDPost-Secondary2 or 4 Year College DegreeGraduate or other Post-Secondary Degree
Non-Cash Benefits Received (Check all that apply to HH)

SNAPWICTANF Child CareTANF TransportationOther TANFOther
Employment Status*

Full-timePart-timeRetiredMigrant Seasonal Farm WorkerNot seekingUnemployed <6 monthsUnemployed >6 months
Eligible for court ordered child support*

YesNo
List amount received per month
Income Received (List all income including wages, TANF, Unemployment, SSI, SSA, Alimony, Workmen's com, etc)
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Northeast Nebraska Community Action Partnership

Basic Intake Form

Head of Household information

Military Information