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Resident Intake Form
Name/Nombre
*
First Name/Nombre
Last Name//Apellido
Allergies to food/ Alergias a los alimentos ?
*
Yes/ SI
No
What foods are you Allergic too? / A cuales Alimenos eres Alergico?
*
Milk/ Leche
Peanuts/ Mantequilla de Mani
Soy/ Soya
Shellfish/ Crustáceos
Eggs/ Huevos
Tree nuts/ Nueces de Arbol
Wheat/ Trigo
Sesame/ Anjojoli
Fish/ Pescado
None/ Ninguno
Other/ Otro
Address/Dirección
*
Street Address/Dirección
Street Address Line 2
City/Ciudad
State/Estado
Zip Code/Código Postal
Phone Number/Número de Teléfono
*
Please enter a valid phone number/Por favor ingrese un número de teléfono válido
Email/Correo Electrónico
*
example@example.com
Ethnicity/Etnicidad
*
Please Select
Hispanic
Non Hispanic
Race/Rās
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian and Other Pacific Islander
White
Other
Number of Household Members/Numero de miembros del hogar
*
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Mark next to the income range that best fits your annual GROSS income & family size/ Marque la casilla junto al rango de ingresos que mejor corresponda a su ingreso BRUTO anual y tamaño de familia.
Household GROSS Income
*
Please Select
$0 - 18,200 Extremely Low Income
$18,201 - $30,300 30-50% of AMI Very Low
30,301 - 48,450 50-80% of AMI Low/Mod
$48,451 - and over Above 80%not Low Mod
$0 - $20,800 Extremely Low Income
$20,801 - $34,600 30-50% of AMI Very Low
34,601 - 55,400 50-80% of AMI Low/Mod
$55,401 - and over Above 80%not Low Mod
$0 - $23,400 Extremely Low Income
$23,401 - $38,950 30-50% of AMI Very Low
38,951 - 62,300 50-80% of AMI Low/Mod
$62,301 - and over Above 80%not Low Mod
$0 - $26,500 Extremely Low Income
$26,501 - $43,250 30-50% of AMI Very Low
43,251 - 69,200 50-80% of AMI Low/Mod
$69,201 - and over Above 80%not Low Mod
$0 - $31,040 Extremely Low Income
$31,041 - $46,750 30-50% of AMI Very Low
46,751 - 74,750 50-80% of AMI Low/Mod
$74,751 - and over Above 80%not Low Mod
$0 - $35,580 Extremely Low Income
$35,581 - $50,200 30-50% of AMI Very Low
50,211 - 80,300 50-80% of AMI Low/Mod
$80,301 - and over Above 80%not Low Mod
$0 - $40,120 Extremely Low Income
$40,121 - $53,650 30-50% of AMI Very Low
53,651 - 85,850 50-80% of AMI Low/Mod
$85,851 - and over Above 80%not Low Mod
$0 - $44,660 Extremely Low Income
$44,661 - $57,100 30-50% of AMI Very Low
57,101 - 91,3500 50-80% of AMI Low/Mod
$91,3511 - and over Above 80%not Low Mod
Please check all that applies/Por favor marque todos los que apliquen
*
Child Care Assistance
Energy Assistance (LIHEAP)
General Public Assistance
Refugee Cash Assistance
Medicaid
RIworks
SNAP(Food Stamps)
SSI or SSDI
Temporary Disability
Unemployment
None/ Ningun Programa
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Appointment Require/ Requere de una cita
Proof of address
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Checked in?
Yes
No
Intake
Completed
Missing ID
Missing 2nd Proof of address
Missing TEFAP
Served as an Emergency?
Yes
No
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: