Financial Aid Intake Form

Applicant Information:
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Preferred Method of Contact*

PhoneEmailMail
Reason for Application (Job Loss, Illness, Reduced Hours, Other - If other, please explain)*

Household Information
Number of People in Household*
List of Household Members (Adults and Dependents) (Name, Age, Relationship to Applicant)*

Income Information
Monthly Household Income*
Sources of Income*

EmploymentSocial Security or SSIUnemploymentChild SupportTANFOther
How Much Per Month from Source of Income?*

Rental Assistance

Subject to verification by GIS to verify address before approval
Rent Due Date*

MonthDayYear
Date
Landlord/Property Management Company Name*
Landlord Contact Information (Phone, Email, Mailing Address)*
Monthly Rent Amount*

Authorization and Agreement
Electronic Signature
Type Your Name
Today's Date

MonthDayYear
I certify that the information provided is accurate to the best of my knowledge*
I authorize the organization to contact my landlord/utility provider for verification *
Disclaimer: Due to high demand, submitting this form does not guarantee assistance.

Please submit this form within a timely manner of your termination/5-14 quit or stay notice because it can take up to a week or longer before you receive a response back.
Should be Empty:

Household Information