Jeffersontown Area Ministries
Financial Assistance Form
Have you been affected by the COVID 19 Virus? (YES / NO) If Yes - Please Explain:
YES
NO
If Yes - Please Explain
Todays Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
**Have you received Financial Assistance from JAM in the past? (YES / NO) If so, Date
YES
NO
If so, Date?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
First Visit
Update (Additional Visits)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Assistance Type(s)
*
Food
Rental Assistance
LG&E
Other
N/A
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Client Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Zip
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Apt #
*
Home Phone
Format: (000) 000-0000.
Cell Phone
*
Format: (000) 000-0000.
Alt #
Do you
*
Own your Home
Rent your Home
Rent your Apartment
Length of time at residence
Apartment Complex
Landlord Name & Phone
Section 8 benefit amount
Foodstamp benefit amount
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Total Household Size
*
Number of Adults (18 - 65)
*
Number of Children (0 - 5)
*
Number of Children (6 - 17)
*
Number of Seniors (60+)
*
Number of Veterans
*
Rows
Last Name
First Name
Relationship
Social Security #
Date of Birth
Age
Race
Gender
SELF
2
3
4
5
6
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Car payment amount
*
Food/Household/Hygiene Expenses
*
Medical Expenses
*
Miscellaneous $
*
Rent $
*
Auto/Home Insurance $
*
Mortgage Amount
*
Phone / Wifi / Cable Expenses
*
Gasoline Expenses
*
Water Expenses
*
LG&E Expenses
*
Child Support/Restitution Expenses
*
Other Expenses (Explain)
*
Total Expenses
*
Expenses Notes
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Wages / Salary Income
*
KTAP / TANF Income
Social Security Income
*
Have you applied for Social Security Disability / SSI
Yes
No
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Social Security Disability/SSI Income
*
Workmans Comp Income
Have you applied for Unemployment Insurance?
Yes
No
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Unemployment Ins Income
Child Support Income
Alimony / Maint. Income
Pension / Retirement Income
Other Income
*
Total Income
Employer Name
Hours Worked (FT / PT)
Spouse/Other Employer
Hours Worked (FT / PT)
Notes on income
Water Account Number:
Is your water bill currently past due?
Yes
No
How much is currently owed on your Louisville Water bill?
LGE Account Number:
Is your LG&E currently past due?
Yes
No
How much do you currently own on your LG&E bill?
Print Email Address
*
example@example.com
I understand that my signature authorizes the release of pertinent information regarding my need for financial assistance. I ensure that the documents I have provided are true and accurate to the best of my knowledge. If it is found that I misrepresented my situation, I will return all monies provided. I understand that my refusal will not result in services being denied. By signing below, I authorize Jeffersontown Area Ministries to inquire about any information I have provided. I also authorize JAM to release information about me or my family to other agencies to secure services and verify eligibility. By typing your name in the space provided, you are submitting the electronic equivalent of a legal signature. Type Full Name
*
First Name
Last Name
Submit
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