Client Assistance Request

The Arc of Buncombe County CRISIS INTERVENTION REQUEST FORM

The Arc of Buncombe County is a nonprofit agency that serves people with intellectual and developmental disabilities (I/DD) in western North Carolina
Client/Child Name*

First NameLast Name
Gender*
Date of Birth*
Enter MM/DD/YYY
Race*
Last four of Social Security Number*
School*
Medicaid*

YesNo
Diagnosis and Medical Provider(s)*
Type of Assistance Requested*
Explain Need/Request
Parent/Guardian Information*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Last Four of Social Security Number*
Email*
example@example.com
County of Residence*
Marital Status*

SingleMarriedDivorcedWidow
Gender*
Date of Birth*

MonthDayYear
Date
Race*
Employment*
Business/Company Name of Employment*
Total Monthly Household Income*
Total # Adults Living in Home*
Total # Children in Home*
I am aware that The Arc of Buncombe County provides financial assistance for crisis situations. Funds are generally distributed to a person or family once in a 12-month period. Checks are written to vendors only.

I agree
I allow permission for The Arc to contact other community organizations regarding my request.

I agree
*To process your application, we will need the application and all requested information included:

-Rental Assistance: copy of lease, landlord acceptance form, mortgage statement, eviction notice

-Auto Payment/Repairs: copy of auto insurance, copy of loan, copy of registration card, copy of current bill, copy of driver’s license

-Utility Payment: copy of most recent bill and copy of disconnect notice if applicable

-Other assistance: copy of quote or bill
Is this a referral from another agency? If so, name of agency.
The information I have provided above is true and accurate. I understand that misrepresentation or falsification of the information above could disqualify me from receiving funds.
Signature*

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Date*

MonthDayYear
Date

INCOME VERIFICATION
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Please list the # of hours worked weekly. Enter 0 if none.*
Enter your gross pay weekly? Enter 0.00 if none.*
Please list all income from the household: (SSA, SSI, SSDI, child support, retirement income, etc.). Please enter for example - $900 per month - Social Security Disability
Amount of income from SSA, SSI, SSDI, child support, etc.
Signature*

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Date

MonthDayYear
Date
NO INCOME/SUPPORT VERIFICATION
Client/Parent/Guardian Name
Date of Last Employment
If you are not receiving any income from any source, we require the form to be signed
Signature

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CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION
I, First Name* Last Name* the undersigned legally responsible person for Client Name* , do hereby consent and grant permission to The Arc of Buncombe County to advocate on behalf of Client Name* to gather and exchange information with any individuals or professionals representing agencies, schools, and local and state facilities pertaining to the welfare of the client.
Date*

MonthDayYear
Date
Signature*

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The Arc of Buncombe County CRISIS INTERVENTION REQUEST FORM

INCOME VERIFICATION

NO INCOME/SUPPORT VERIFICATION

CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION