COMMUNITY ACTION

How can we help you? *

Please select the program you're interested in

Affordable Housing

Head Start/ Early Head Start

Rent Assistance

Utility Assistance

Diaper Depot

Period Pantry

Food Assistance

Name *

First Name

Last Name

Primary Number *

(###)

###

####

Secondary Number

(###)

###

####

Physical Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you a Community Action employee? *

Yes

No

Are you or anyone in your household related to a Community Action employee(s)? *

Yes

No

NON-CASH ASSISTANCE RECEIVED *

Assistance Received. Check all applicable types. Cash Assistance & Medical Insurance are reported elsewhere

WIC

LIHEAP

Section 8

Shelter Plus Care

SNAP/Food Stamps

Insurance Subsidy

Permanent Supportive Housing

Other Public Housing

CSFP/TEFAP Commodities

Childcare Voucher

HUD VASH

EITC

Name *

APPLICANT INFORMATION (Person Completing the Application)

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Gender *

Male

Female

Other

Disabled? *

Yes

No

Latino? *

Yes

No

Race – Check All that Apply *

African Am/Black

Am Indian/Alaskan

Asian

Hawaiian/Pacific Islander

White

Other

Education *

0-8

9-12 Non-Grad

High School Grad/GED

Some College

2 or 4-year College Grad

ATTESTATION & UNDERSTANDING *

I attest that the information: 1) was provided voluntarily and 2) it is correct and complete. I understand that: 1) the information will be kept confidential pursuant to the Privacy Act of 1974, as amended, but may be made known to other persons in pursuit of eligibility determination, funder reporting, and central data system reporting; and 2) any false statements could result in the denial of services.

First Name

Last Name

Date

MM

DD

YYYY