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
**Have you received Financial Assistance from JAM in the past? (YES / NO) If so, Date
YES
NO
If so, Date?
-
Month
-
Day
Year
First Visit
Update (Additional Visits)
-
Month
-
Day
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
1
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
Social Security Disability/SSI Income
Workmans Comp Income
Have you applied for Unemployment Insurance?
Yes
No
Date
-
Month
-
Day
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
Type Full Name
First Name
Last Name
Submit
Should be Empty: