Client Assistance Form
Prior Last Name (if applicable)
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
Drivers License / Michigan Identification Number
Household Resident #1 w/Birthdate
Household Resident #2 w/Birthdate
Household Resident #3 w/Birthdate
Household Resident #4 w/Birthdate
What has caused or contributed to your financial difficulties?
Other (specify below)
If you selected Other, please describe
What kind of assistance are you in need of? Please note that we do NOT assist with court fees, child support, transportation, or vehicle repairs.
If you are being evicted, have you received an eviction notice? If so, please list the date that you must leave and the amount owed in order to avoid eviction.
Have you received financial assistance elsewhere? If so, where?
Do you have an active Bridgecard from DHS? If so, please state the monthly dollar amount?
Do you receive funding from SSI or for disability? If so, please state the monthly dollar amount.
Are you a U.S. Veteran?
Should be Empty: