H.A.L.O. Community Assistance Intake Form
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
E-mail
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Hispanic or Latino
Prefer Not to Say
Marital Status
*
Single
Married
Divorced
Widowed
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have chidren in the home
*
Yes
No
Please list child(ren) age(s). (Example: John age 6)
*
Please explain below what caused you to be behind in payments or need assistance.
*
Have you received assistance in the past 12 months from any other agency, organizations, churches?
*
No
Yes
If you answered "yes" to question above, please list the organization/church.
*
Are you disabled?
*
Yes
No
Disabled Vet
State Issued DL/ID
*
Please Select
ID
Drivers License
Upload your identification files
*
Browse Files
Drag and drop files here
Choose a file
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of
Bill Uploading
*
Please Select
Atmos Gas Bill
Electric Bill
Water Bill
Account Number
*
Upload your bill files
*
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Choose a file
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Please upload proof of income, such as a recent pay stub, employment verification letter, Social Security or disability award letter, bank statements showing direct deposits, or any other official documentation, in PDF, JPG, or PNG format.
*
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I certify that all information I provide is true. I authorize H.A.L.O to contact service providers to verify my account if needed. I understand assistance is case-by-case, and I may join other programs to improve my well-being.
*
Yes
Yes, I agree to have my basic information entered into the H.A.L.O. computer system to receive assistance.
*
Yes
Signature
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