Client Assistance Form
Name
First Name
Last Name
Prior Last Name (if applicable)
Birthdate
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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?
Income Reduction
Unemployment
Medical Bills
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 medical expenses, court fees, child support, transportation, home or vehicle repairs.
Rent
Housing
Utility
Food
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?
Yes
No
Submit
Should be Empty: