WorkSource Funding Intake Form
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Household & Eligibilty (Grant Qualifiers)
*
Please Select
Unemployed
Underemployed
Employed
Prefer not to say
Current Employment Status
Household Size
*
(“How many people live in your household, including you?”)
Approximate TOTAL monthly household income
*
Please Select
Under $1,000
$1,000 – $1,999
$2,000 – $2,999
$3,000 – $3,999
$4,000+
Not sure
Do you currently receive government assistance?
*
Yes
No
Not sure
If yes, which program(s)?
*
SNAP / EBT (Food Stamps)
Medicaid
TANF
SSI / SSDI
Housing assistance (Section 8, etc.)
WIC
Unemployment benefits
Other
Submit
Should be Empty: