ELKO Homeowner Questionnaire

Assistance Request Form

At this time, we are not accepting assistance requests. Thank you. - The Good Deed Project
Assistance Request

Please fill out this form to request assistance or refer someone for assistance. Please note that filling out this form is just a request and does not guarantee receiving assistance. Services are limited and referrals will be vetted. Application cannot be saved and completed at a later time, so please review questions before you start and have all necessary information on hand.
Interviewer Name*

First NameLast Name
What type of home do you live in?*

Single-family house one story - Owner occupiedSingle-family house two story - Owner occupiedCondominium one story - Owner occupiedCondominium two story - Owner occupiedSingle-family house - RentedSingle-family house - Rented (with rental assistance)Apartment/Condominium - RentedApartment/Condominium - Rented (with rental assistance)Manufactured Home: Trailer Home; single-wideManufactured Home: Trailer Home; double-wideTransitional housing: Moving into new, independent living space from homelessness or shelter (homeless shelter, domestic violence shelter, half-way house, etc.)Temporary Living: Renting Bedroom(s)Temporary Living: Weekly MotelExperiencing Homelessness
Today's Date

MonthDayYear
Date
Referral

Please let us know how you heard about us/our services.
Are you filling out this form for yourself?*

YesNo
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
What kind of organization are you with?*
What organization/school are you with?*
Personal information

Fill out the following information for the person for which assistance is being requested
Client Name*

First NameLast Name
Are you head of household?*

YesNo
Head of Household Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email Address
example@example.com
Address*

Street Address

Unit #

CityState / Province

Postal / Zip Code
Residency Status

U.S. CitizenPermanent Resident (Green Card)Refugee/Asylum StatusOther
Race*

American Indian or Alaskan NativeAsianBlack or African AmericanCaucasian/WhiteHispanicNative Hawaiian/Pacific IslanderPrefer not to answerOther/Unknown
Ethnicity*

Hispanic or LatinoNon-Hispanic or LatinoPrefer not to answerOther/Unknown
How many total people live in the household?*
How many adults live in the household?*
How many children live in the household?*
How many pets in the household?*
List (first) names and ages of those living in the home.*
Check any of the following conditions that apply to anyone in the household.*

VeteranSeniorDisabledSpecial needsSingle parentUnemployedNone of the above
Please provide any details on conditions:
Select any that apply:

ActiveInactiveService-DisabledOther
Select any of the following that apply to children living in the home.*

All children are biologically the head of household's or a stepchildOne or more children in the household are foster childrenOne or more children in the household are legally adoptedOne or more children in the household are under my legal guardianshipOne or more children in the household belong to a family member but are cared for by head of householdOne or more children in the household belong to a family member, who also lives in the householdNot applicable - There are no children in the household
Approximate square footage of the home:*
How many bedrooms are in the home?*
Was your home built before 1978?

YesNo
Is there lead paint present in the home?

YesNoUnknown
Is there asbestos present in the home?

YesNoUnknown
Condition of the home:*
Tell us why you need assistance, about any special circumstances and how receiving services from The Good Deed Project would impact your situation.*
Describe any special circumstances and how receiving services from The Good Deed Project would impact your situation.*
Type of assistance you are requesting (check all that apply)*

MattressHousehold furnitureHome repairHome renovationHome Assessment
Describe your sleeping situation that necessitates you getting a new mattress. (Please note that available mattresses are queen size sofa mattresses that are thinner and do not include a box spring.)*

Sleeping on the floorSleeping on an air mattressSleeping on a couchOther
If you chose "Other," please describe situation.*
How many mattresses are you in need of?*
What furnishings are you in need of?*

BedframeCouchKitchen table/chairsNightstandLightingOther
If you chose "Other," please list needed/desired items.*
Please provide the name of the community/subdivision you live in as well as the name, phone number and any other contact information you have for the homeowner, management company or person responsible for the home. *
Describe what needs to be repaired/renovated and why the issues create a particularly hazardous situation for you/your family.*
Upload photos that show the condition of the home/space that needs to be repaired*

Cancelof
Financial information

Your answers to the following questions do not necessarily disqualify you from being considered for services from The Good Deed Project. Please answer them as completely and accurately as possible.
How many people in the household are employed?*
Gross annual income (for entire household)*
If you receive any child support or payments for fostering children, please list monthly amount. If not, type N/A.*
Do you receive any type of assistance (monetary, food, housing vouchers, etc.)? If so, please list source and amount received monthly.*
If you have any type of case worker, please list their name and organization.
Best time(s) to contact you*

MorningsAfternoonsEvenings
Best day(s) to contact you*

SundayMondayTuesdayThursdayFridaySaturday
How did you hear about us?*

Friend/family member/colleagueSocial mediaVolunteer organizationProfessional/social organizationGoogle search/our websiteSaw a news story (on TV, online or in print)School/recreation centerFamily who received help from The Good Deed ProjectOther
Please identify source*
Please provide the name of the family member/friend/colleague*
Which social media platform did you find us on?*

FacebookInstagramLinkedIn
Please select the organization*

JustServeUnited WayNevada VolunteersNational Charity LeagueOther
Please identify source*
Please provide the name of the organization*
Please provide the name of the school/recreation center*
Please provide the last name of the family*
Notes
Should be Empty:

Assistance Request Form

Assistance Request

Referral

Personal information

Financial information