Supportive Services Form

TANF Supportive Services

Assistance Application
Name*

First NameLast Name
E-mail*
So that we can get back to you
Birth Date*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you currently on a housing voucher or receiving subsidized rent? *
Those who are on a housing voucher to pay their current rent or receiving subsidized rent may be ineligible for supportive service assistance.
If yes, please list the housing authority your voucher is from or who is subsidizing your rent.
What was the gross (before taxes) income of your household for the last 30 days?*
Please include the gross income of all working adults in your household that contribute to your household finances.
Are you or your spouse/partner legally eligible to work in the United States? *
If you are on disability, but otherwise would be legally eligible to work in the United States, please answer "Yes"
Do you currently live in Weber, Davis, Box Elder, or Morgan county?*
Are you a current client with Cottages of Hope?*
Who referred you to our organization?*
Have you or your partner, at any time in your lifetime, been incarcerated?*
Including yourself, how many individuals in your household are over the age of 18? blank*
How many dependents do you have under the age of 18? (Must have children to qualify for supportive services) blank*
Do you have at least 50% custody of at least one of your dependents?*
What school districts are your dependents in? blanks*
Dependents
Do you currently have an eviction notice?*
What kind of assistance are you requesting? *
Please describe your request in detail:*
Please describe, in detail, what led up to your current situation:*
If assistance is granted, what is your plan on how you will afford your housing costs and bills the following month? (We do not provide long term housing) *
Are you currently receiving, or have you received within the last 12 months, any of the following?*
Please list what other agencies you have worked with in the last year and what services they provided you: ex. Rent relief, housing vouchers, foodstamps, FEP, education assistance, etc.*
Required Documentation

Specific documentation is required to verify eligibility.
The following documents are required to verify eligibility. Please bring them with you to your first appointment. Please select which documents you have available.
The following questions regarding employment, employment history, and education are optional and do not impact eligibility.
Are you currently employed?
If you are not currently employed, do you have a job offer? If so, when do you expect to start?
Please describe your employment history for the last two years including dates:
Are you currently attending or planning on attending school? If so, what area of study?
After receiving your intake phone call, your first appointment will be attending our financial workshop, Budget 101. Budget 101 is held every Wednesday from 10:00am am until 11:30am, and attendance is required.

We ask participants to arrive 10 to 15 minutes early as doors close promptly at 10:00am. If you arrive after the classroom doors have closed, you will not be permitted to participate in that session and must attend a session in the future.

We ask that you do not bring any children to the class. If you do arrive with children, you will not be able to participate in the class.

Please type your full name to sign stating you agree to attend the workshop and understand the attendance policy. blank*
I hereby certify that the information provided in this form is complete, true, and correct to the best of my knowledge. Further, I hereby understand that this assistance is not guaranteed. I acknowledge that this process could take up to 30 days for a decision to be made once Budget 101 is attended and all required documents are presented.

Please type your full name to sign this acknowledgment. blank*
Should be Empty:

TANF Supportive Services

Required Documentation

The following questions regarding employment, employment history, and education are optional and do not impact eligibility.