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?
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?
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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?
Head of Household Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Unit #

CityState / Province

Postal / Zip Code
Residency Status
Race
Ethnicity
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.
Please provide any details on conditions:
Select any that apply:

Other
Select any of the following that apply to children living in the home.
Approximate square footage of the home:
How many bedrooms are in the home?
Was your home built before 1978?
Is there lead paint present in the home?
Is there asbestos present in the home?
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)
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.)

Other
If you chose "Other," please describe situation.
How many mattresses are you in need of?
What furnishings are you in need of?

Other
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
Best day(s) to contact you
How did you hear about us?

Other
Please identify source
Please provide the name of the family member/friend/colleague
Which social media platform did you find us on?
Please select the organization

Other
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