Weatherization BIF Page 2

Northeast Nebraska Community Action Partnership

Basic Intake Form Page 2
Head of Household Name*

First NameLast Name
Relationship to Head of Household*

Spouse/PartnerChildOther RelationOther Non-Realation
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number
Gender*

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

AsianWhiteAmerican Indian/Alaska NativeBlack/African AmericanNative Hawaiian or Pacific Islander
Ethnicity*

Hispanic/LatinoNon-Hispanic/Latino
Are you Disabled*

YesNo
Long Term Disabled

YesNo
Type of Disability

PhysicalMentalDevelopmentalChronic HealthHIV/AIDSSubstance AbuseOther
Health Insurance Status*

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

No SchoolingPreK - 4th grade5th - 6th grade7th - 8th grade9th grade10th grade11th grade12th gradeHigh School DiplomaGEDPost-Secondary2 or 4 Year College DegreeGraduate or other Post-Secondary Degree
Working or in school if age 14-24

YesNo
Answer only if person above is age 18 or over
Active Military*

YesNo
Veteran*

YesNo
Year Entered
Year Seperated
Branch
Discharge Status
Theater of Operation

World War IIKorean WarVietnam WarPersian GulfAfghanistanIraqi FreedomIraq-New DawnOther Operation
Are you current or ever been in Foster Care*

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

YesNo
When?
Are you Currently Fleeing

YesNo
Employment Status*

Full-timePart-timeRetiredMigrant Seasonal Farm WorkerNot SeekingUnemployed <6 monthsUnemployed >6 months
Income Received (List all income including wages, TANF, Unemployment, SSI, SSA, Alimony, Workmen's comp, etc)
Signature*
Date*

MonthDayYear
Date
Should be Empty:

Northeast Nebraska Community Action Partnership

Answer only if person above is age 18 or over