Client Request Form

Love INC of Greater Merced

Please make sure to agree to our terms of service and note that all questions with an * must be answered or you will not be able to submit your form.
Have you received services from Love INC in the past 3 years? *

Yes No
If Yes, What name would your file have been under?
Today's Date:

Month Day Year
What is your specific need today? (Please only one and select the most urgent need.)

Food I.D.'s Ride Baby Basket Diapers Formula Furniture Toiletries
Full Name *

Prefix First Name Middle Name Last Name
D.O.B. *

Month Day Year
Last four SSN#: *
Personal Phone:

Area Code Phone Number
Alternate Phone:

Area Code Phone Number
Physical Address: *

Street Address

Street Name, Lot / Apt. #

City State

Zip Code
Is this Apt/House/Mobile home?
Complex Name:
Mailing Address:

Street Address

Street Name, Lot / Apt. #

City State

Zip Code
E-mail
Status:
Mate's Name:

First Name Last Name
Mate's D.O.B.:

Month Day Year
Mate's SSN:
Which Church do you attend?
Do you have Children at home?

Yes No
Total in Family:
Total in Household:
Child Info:
Are there others in your home besides you, your mate, and/or children listed above?
How long have you lived at your address?
Have you been a resident of Merced County for 6 months or longer?

Yes No
Do you...
Rent?
Own?
Staying with Someone?
Full Name

First Name Last Name
Relationship:
Phone Number

Area Code Phone Number
How long do you plan to stay?
Does an agency assist you with your rent?

Yes No
If Yes, please fill out below. If No, leave blank move on to Rent or Mortgage amount.
Which one Assists?
What is the portion of rent they pay?
How much is full rent or mortgage amount?
How much do you pay?
Landlord or Mortgage: *

First Name Last Name
Phone Number

Area Code Phone Number
Are you current on your rent or mortgage?

Yes
Due Date:

Month Day Year
Amount owed Eviction or foreclosure notice?
FURNITURE REQUESTS ONLY!
Are you willing to have someone visit you to evaluate your furniture needs?

Yes No
Are you willing to pay a $10.00 Process & Delivery Fee following the Home Assessment?

Yes No
Day & Time Availability:
Income & Expense evaluation section

Please type numbers only, this is for monthly income totals.

Household Members Income *

Client's Amt.

Mate's Amt.

Other

Food Stamps

Cash Aid

Disability

Vet's Disability

Other Grants

Medi-Cal/Medicare

WIC

Self-Employment

Wages(Net)

Unemployment

Social Security (Retirement)

Retirement/Pension

Veteran’s Retirement

Child Support/Alimony

Other

Total Household Member Income

Household Members Expenses *

Client's Amt.

Mate's Amt.

Other

Rent/Mortgage

Electricity/Gas(PG&E/MID)

Other Utilities(W/S/G)

Phone

Internet/Cable

Groceries/Food

Car Payment

Car Insurance

Credit Card/Loans

Eating Out/Movies

Toiletries (hygiene, etc.)

Haircuts/Beauty/Nails

Gas/Bus/Transportation

Health Insurance

Medical Bills/Prescriptions

Clothing, Shoes, etc.

Payday/Rent to own Loans

Education(books, supplies)

Child Support/Alimony

Other (Cigs./Alcohol)

Total Household Member Expenses
Income minus Expense Balance
If balance is a negative amount, please state how you make it work since you spend more than you make?
Who referred you? (Please be specific.)

First Name Last Name
Do they recieve services through Love INC?

Yes No
Phone Number

Area Code Phone Number
Have you applied elsewhere for assistance?

Yes No
Where have you applied?
Other:
Have you Contacted family/friends for assistance?

No
What Happened?
Do you have a caseworker?

No
Caseworker Name

First Name Last Name
Phone Number

Area Code Phone Number
May we Contact?

Yes No
Details about Need
Please share a little bit about the circumstances that led you to have this need.
Future Direction
Will your household size change in the next 3 months?

Yes No
Love INC provides classes in budgeting, nutrition & exercise, soft vocational skills and healthy relationships. Would you like to know more about these opportunities?

Yes No
Verification Documents

In order to verify the information you provide we will need proof of income and proof of residence. Verifications of income inclide copies of all forms of income in the household (SSI, Wages, Disability, Grants, TANF, etc.) Verifications of residence include the front page of a Rental/Lease Agreement--this is required for furniture requests --OR a current PG&E bill. You can upload legible photos of the necessary documents below.
What is something you’re grateful for today? *
We hope you have been encouraged by getting an opportunity to share your story. As we work with you over the next few days, we want to encourage you, believing that God values you and wants to improve your life.
Please sign to approve this document (click and hold mouse to draw signature, or with finger on mobile)
Signature

Clear
Should be Empty:

Client Request Form

FURNITURE REQUESTS ONLY!

Income & Expense evaluation section

Details about Need

Future Direction

Verification Documents

We hope you have been encouraged by getting an opportunity to share your story. As we work with you over the next few days, we want to encourage you, believing that God values you and wants to improve your life.