Client Intake Form. Food Pantry USDA Commodities Weatherization Utility Assistance Migrant Services Date: Head of Household Last First

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1 Client Intake Form Food Pantry USDA Commodities Weatherization Utility Assistance Migrant Services Date: Head of Household Last First Street Address City Zip Code Township Telephone # Date of Birth Gender Female Male Primary Race American Indian or Alaskan Native Native Hawaiian or other Pacific Islander Asian Black or African American White Multi-racial SS# Ethnicity Hispanic/Latino (Non-Hispanic/Latino) U.S. Citizen Veteran Marital Status Education Level Married 0-8 Divorced 9-12 (non-grad) Separated HS Grad/GED Single Some College Widowed College Grad Disabled Employment Status Full time above minimum wage with benefits Full time above minimum wage without benefits Full time at minimum wage with benefits Full time at minimum wage without benefits Part time above minimum wage with benefits Part time above minimum wage without benefits Part time at minimum wage with benefits Part time at minimum wage without benefits Seasonal work Volunteer work only Unemployed - with work history and skills Unemployed - without work history or skills Unemployed - by choice Retired

2 Housing Homeowner, safe and affordable (includes condominium or co-op) Homeowner unsafe or unaffordable n-subsidized rental housing, unlimited choice safe and affordable n-subsidized rental housing, limited choice safe and affordable Subsidized Section 8 rental housing, safe and affordable Subsidized Section 8 rental apartment, safe and affordable Subsidized public housing, safe and affordable Subsidized rental, unaffordable or unsafe n-subsidized rental, unaffordable or unsafe Transitional housing, safe Temporary shelter Living with friends or relatives Homeless, house is substandard or unsafe Homeless Homeless by choice Transportation Family members always have transportation needs met through public transportation, a car, or a Family members have most transportation needs met through public transportation, a car, or a Family members have some transportation needs met through public transportation, a car, or a Family members rarely have transportation needs met through public transportation, a car, or a Family members do not have transportation needs met through public transportation, a car, or a Childcare children in household Child enrolled in unsubsidized, licensed childcare setting of own choice Child enrolled in unsubsidized, licensed childcare setting of own choice Child(ren) in household do not require childcare Child enrolled in licensed subsidized childcare of own choice Child enrolled in licensed subsidized childcare limited choice Child provided childcare by a family member or friend Child not enrolled in childcare Child enrolled in unregulated or unlicensed childcare facility Food Family able to afford most food or meet basic need Family able to afford some food but occasionally uses food bank or food stamps to meet basic need Family unable to afford food but uses food bank or food stamps to meet basic need Family unable to afford food to meet basic need

3 Food Stamps $ monthly Clothing Family able to afford clothing to meet basic need Family able to afford some clothing but occasionally uses clothes closet or clothing assistance Family unable to afford clothing uses clothes closet or clothing assistance Family unable to afford clothing to meet basic need Health Insurance Medicine Family has health insurance Family able to afford medicine/ basic need Family has access to health insurance Family able to afford some medicine Some family member have health insurance uses prescription assistance Some family members have access to health insurance Family unable to afford medicine Family has no access to health insurance uses prescription assistance Family unable to afford medicine to meet basic health needs Independent Living Senior/Disabled in household Family member is able to live independently without assistance Family member is able to live independently with some assistance Family member is unable to live independently and needs assistance Family member is unable to live independently Education Special Needs special needs child in household Family is able to provide support to special needs child Family is able to provide support to special needs child with some assistance Family is unable to provide support to special needs child and needs assistance Family is unable to provide support to special needs child. Cause of Crisis From the following crisis points choose 3 that most accurately identify conditions creating need for assistance. Financial Unemployed (less than 2 years) Unemployed (greater than 2 years) Employed (unexpected circumstance creating financial crisis) Job status change or hours cut Underemployed (employed but wages do not cover debts, less than 2 years) Underemployed (employed but wages do not cover debts, greater than 2 years) Unable to work Retired (fixed income) Loss or reduction of Federal/State Benefits Personal Unreliable or lack of transportation Unreliable or lack of child care Loss in family Illness in family Separation or Divorce Loss of home Emergency Home Repairs/Appliances needed Inefficient home or Inefficient Appliances Health Acute illness causing financial hardship Chronic illness causing financial hardship Family member with acute illness causing financial hardship Family member with chronic illness causing financial hardship Disability

4 Additional In the spaces below add any additional conditions creating need for assistance Household Information Type: Two Parent Household Female Single Parent Male Single Parent Grandparent and Child Additional Houshold Members: Single Person n -custodial Caregiver Two Adults/no children Fill out for Household members 18+ Name Gender Date of Birth Age Social Security Number Relationship to Head of household Education Level (Write-in 1-5) Work Status (FT/PT/UN) *see key below Example: John Doe M 9/14/ Spouse 3 PT Current Source(s) of Income For Household Check all that apply and write the amount in the space provided *Education-Level Key: 1) Attended 0-8 Grade 2) Attended 9-12 Grade (did not Graduate) 3) HS Graduate/GED 4) Some College 5) College Graduate Income Alimony Child Support Employment Pension/Retirement Self Employment Social Security RSDI SSI State Disability TANF Veteran s Pension Worker s Comp Unemployment

5 I, the undersigned, give my consent for Allegan County Resource Development Committee, to make only the contacts necessary to determine my eligibility for various programs and/ or to refer my case to an agency that may provide additional services. This consent form is valid for no longer than one (1) calendar year from the date signed. I can withdraw my consent at any time. Client Signature Date ACRDC Staff Signature Date Office Use Only: Total Monthly Income $ Total Annualized Income $ Family of Eligible at % This institution is an equal opportunity provider.

6 Housing Information Form Area Type: City/Town Rural Area Suburb Stories One Story One and a Half Story Second Story Third Story Four Story Structure Type Wood Frame Brick Masonry Mobile Home Multi-Unit Dwelling Type Site Built Multi Unit Mobile Home Double Wide Modular Home Duplex Row House 3 to 4 Unit Rental Year of Home Construction if unknown approximate age How many smokers in the household Was dwelling previously weatherized? When If home was previously weatherized has the home been damaged by fire, flood, wind or any other act of god? When? Monthly Rent or Mortgage Payment Unvented non-electric space heaters? How many? Water Heater Type Designated for acquisition or clearance by federal, state, or local program within 12 months? If renting and being weatherized, what is owner s contribution? SEV Housing Exposure Exposed Normal Shielded Primary Heating Fuel Natural Gas Propane Fuel Oil Electric Wood Secondary Heating Fuel Natural Gas Propane Fuel Oil Electric Wood Housing Documents Warranty Deed Title Vendor Name Vendor Acct. Number Vendor Name Vendor Acct. Number