Financial Service Request
Caseworker Name:_________________________________
Date
*
-
Month
-
Day
Year
Date Picker Icon
Describe your emergency
*
Name
*
Prefix
First Name
Middle Name
Last Name
Suffix
Aliases (Nickname, Preferred Name)
How did you hear about us?
Dept. of Social Services
Church
Friend/Neighbor
Referred by Haven
Website
Other
Residence Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
mm-dd-yyyy
Gender
Male
Female
Not Specified
Ethnicity
American Indian/Alaskan
Asian
Black or African American
Hispanic
Native Hawaiian/Other Pacific Islander
White
Multi-Racial
Other
Marital Status
*
Married
Single
Divorced
Widowed
Partnership
Separated
Other
Preferred Phone Number
ex: (434) 222-2222
Phone Type
*
Cell
Home
Work
Other
Email
example@example.com
Preferred Contact Method
*
Email
Phone
Text
Only check these if you do not wish to be contacted this way. You may miss out on important notifications.
Do not call
Do not text
Spouse/Partner living in household
*
Yes
No
Spouse/Partner Full Name
Prefix
First Name
Middle Name
Last Name
Suffix
Partner Date of Birth
-
Month
-
Day
Year
mm-dd-yyyy
Partner Gender
Male
Female
Not Specified
Partner Ethnicity
American Indian/Alaskan
Asian
Black or African American
Hispanic
Native Hawaiian/Other Pacific Islander
White
Multi-Racial
Other
Partner Preferred Phone Number
ex: (434) 222-2222
Phone Type
Cell
Home
Work
Other
Partner Email
example@example.com
Additional Household Members (other than applicant and partner):
Rows
Full_Name
Date_of_Birth
Gender
Relationship
Ethnicity
Member 1
Member 2
Member 3
Member 4
Member 5
Member 6
Attend Church?
Yes
No
If Yes, Primary Church
Drivers License/ID Number
*
Drivers License/ID Expiration Date
*
-
Month
-
Day
Year
Date
Other Assistance: Do you have a social worker or case worker? If yes, please provide full name and where located. List any items you have requested and received from this other agency.
Please check all that apply:
Disabled -- Enter Date disability began
Able to work
Veteran
Living Arrangement
Single Mother
Single Father
Two Parent
Couple
Single
Other
Eviction
Received Eviction Notice
Been Evicted
Enter Eviction Date
-
Month
-
Day
Year
Date
Housing StatusPermanence of Living Situation
*
Own
Rent
Section 8
Live with friend or family
Rent a room from someone
Rent out a room to others
Homeless
Other
Date Housing Arrangement Began
-
Month
-
Day
Year
Date
Would you or your family benefit from counseling services?
Yes
No
Would you be willing to take budgeting classes or receive budgeting counseling if available?
Yes
No
If yes, describe any budgeting or counseling needs
Would you be willing to be a volunteer with GRACE?
Yes
No
GIFTS AND ABILITIES: Please describe any special abilities and talents you have that you enjoy and others like about you. (Optional)
Employment/Income Status
Employed
Disability/SSI
Recently lost job/laid off
About to start new job
Between Jobs
Unable to work
Retired
Unwilling to work
Other
Employer Name
Date Employment Began or will Begin
-
Month
-
Day
Year
Date
Date Employment Ended
-
Month
-
Day
Year
Date
Take home income per month
ex: 700
Unemployment Benefits Status
Unemployed receiving benefits
Unemployed not receiving benefits
Other
Amount of unemployment per month
ex: 400
Further explanation of unemployment:
What is your request?
Household Items (Bag)
Household Items (Large)
Utility Assistance
Rent/Mortgage Assistance
Prescription Assistance
Vehicle Repair
Counseling Referral
Prayer
Other (describe below)
REQUEST: Describe your request
*
VERIFICATIONS: Please provide:
Proof of Emergency (if possible)
Proof of Income
Proof of Employment
Signed Consent Form
Budget Worksheet
Verification Sheet-Related Utilities/Landlord/Employers detail
Budget Form and Verification Information
Enter Household Income Amounts
Rows
Monthly Income
Cash Assistance
Child Support
Employment/Wage (Net)
Family Assistance
Other Income
Retirement/Pension
Social Security Income (SS)
Spousal Support
Unemployment
TOTAL HOUSEHOLD INCOME
Enter Government Assistance Income Amounts
Rows
Monthly Amount
Disability Insurance (SDI)
Disability (SSI)
Food Stamps
Medicare/Medicaid
Other Grant
Subsidized Rent Amount
Veteran's Benefits
WIC
TOTAL GOV. ASST. INCOME
Enter Monthly Expense Amounts
Rows
Monthly Amount
Alcohol
Cable/Internet
Car Insurance
Car Payment
Cigarettes
Clothing
Contributions
Credit Card Loans
Daycare
Education
Electricity
Entertainment
Food (full amount incl. food stamps)
Gas (for house)
Gasoline (car)
Homeowner's Insurance
Laundry
Medical Bills
Medical Insurance
Mortgage
Other
Other Utilities
Pay Child Support
Phone (landline/cell)
Property Tax/Other
Rent (full amount)
Student Loan Payment
Subscription Services
Tithe
Toiletries/Cleaning Products
Vehicle Maintenance
Water
TOTAL EXPENSES
MONTHLY EXCESS OR DEFICIT
Rows
TOTALS
TOTAL HOUSEHOLD INCOME
TOTAL GOVERNMENT ASSISTANCE
LESS TOTAL EXPENSES
EXCESS OR DEFICIT AMOUNT
Applicant Signature: By signing this form you certify that all information is accurate and complete to the best of your ability.
*
Written Signature and Date
Signature
Depending on your request, provide verification detail below.
Company/Landlord/Other Name
Company/Landlord/Other Contact Phone
Account Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please upload a copy of your current Driver's License or ID - you must be a resident of Greene County.
Browse Files
Cancel
of
Please upload a copy of your current income source. For example, pay stub, Government assistance letter (SSI), bank statement showing deposits, etc.
Browse Files
Cancel
of
Please upload a copy of the bill you wish us assist with or a copy of your lease/rental/Mortgage agreement
Browse Files
Cancel
of
Please upload a copy of the signed GRACE Consent Form. See link to this form, download and sign, then upload here.
Browse Files
Cancel
of
Submit
Should be Empty: