Eligibility Form

All information entered is secure and confidential.

Answer each question below to the best of your ability. Once submitted, your screening form will be sent to Family Promise of the Jersey Shore team for review. A case worker will contact you via phone and/or email once your screening is reviewed to collect any additional information necessary. Please note, case managers are working hard to help you and it will take time to review your case.

You will then be prompted to provide documentation (e.g., banking information, identification, proof of hardship, etc.) to support your answers to the questions below. Family Promise of the Jersey Shore case workers will work with you during the document collection process and, if found eligibile for services, you will be scheduled for an in-person appointment to complete an application for program enrollment.

If you are not eligibile for services or if Family Promise of the Jersey Shore does not currently have funding to assist your family, we will provide you with referrals to other agencies that may be able to assist you promptly.

We look forward to working with you!

Name*

First NameLast Name

Your Gender*

Email*

example@example.com

Who Referred you to our Agency?*

What is your First Language? *

example: Spanish or English

Address (If you are homeless please list Town you became homeless in & Town you are currently located in)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number. By providing your phone number you consent to receive text messages and take phone calls.Format: (000) 000-0000.

Your Social Security Number (or just last 4 digits) *If you have no SSN put 0000*

Your Date of Birth*

Do you have a NJ Drivers License or NJ State ID? If no, what State are you a resident of?*

Do you Rent or Own?

Do you get child support? If yes, how much monthly?*

Do you get food stamps?*

Do you have health insurance? If yes, is it State insurance or Self Pay insurance?*

If you are looking for Security Deposit how much do you need?*

How long have you been at this address?

How long have you been in this situation?

Please describe your situation.*

If seeking shelter, where did you sleep last night?

Do you have a working vehicle?*

If you DO NOT have a working vehicle what plan do you have to provide transportation for yourself 24/7?*

If seeking financial assistance for rental arrears, security deposit, or utility assistance, what caused you to fall behind or not be able to pay?

Address you are moving to (for relocation assistance only)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

YesNo

(if Security Deposit needed) What is Move in Date of Approved New Rental? blanks

Please list FIRST/LAST NAME and DATE OF BIRTH for all adults (18 and over) in household & their RELATIONSHIP to you (example: "John Doe 1/1/2000 - Son"*

Please list children 17 yrs old or younger: FIRST/LAST NAME and DATE OF BIRTH in the household ALSO, list the SCHOOL they attend and their RELATIONSHIP to you (example: "Jane Doe 1/1/2020, ABC Elementary, Daughter"*

Anyone in the household have any medical or mental health conditions they are in treatment for? If yes, please detail.*

Do you have a Rental Voucher or Section 8? *

Are you currently pregnant? If yes, what is due date?*

Are you a veteran?*

Anyone in the household have any alcohol/drug issues in the past or present? If yes, please detail.*

Anyone in the household have any criminal background? If yes, please detail.*

Marital Status*

Do you have a court date for eviction or warrant of removal? If yes, please list the date and if it is for court or for warrant of removal.*

List PER PERSON in household the INCOME they bring into the household monthly and if it is from EMPLOYMENT, SSI/SSD, other*

example: Jane Doe $1000/month from Employment

How much is your base rent? (Do not include pet fees, late fees, any other fees)*

1234 or more

If you are behind in rent or utilities, what is the total amount you owe the landlord or utility provider?

What other agencies have you applied to for assistance in the last 12 months and what was the outcome? (Include how much financial assistance you received or information about a denial for assistance.)

If Family Promise of the Jersey Shore is able to assist, please describe your plan moving forward on how you will continue to keep up with your expenses?

If you are experiencing an immediate housing crisis or do not have a place to sleep tonight, please contact 2-1-1 at any time during any day.

* I have read, understand, and agree to the information sharing agreement above

* I have read, understand, and agree to the Nondiscrimination policy above

Signature for Information Release

Eligibility Screening