Printing Instructions:  Please use your print button on your internet explorer to print the application.  You might want to look at the print preview to be sure all of the application prints on 4 pages (2 of instructions and 2 of the application).  If you have any problems, please contact the Community Dental Clinic.

Utility Information

   How does the family pay for Heating & Cooling?  To the Utility Company     To the Landlord

 

                Electric Service Vendor:  ______________________________ Heat    Cool    Both

                Natural Gas Vendor:  ________________________________ Heat     Cool     Both

                Propane Vendor:  ___________________________________ Heat     Cool     Both                  

   Other Energy Vendors:

Name:  ___________________________________________    Fuel Type:  ___________________

Name:  ___________________________________________    Fuel Type:  ___________________

 

Confidentially Statement:  Information shared with C-SCDC staff will be kept strictly confidential.  These forms will be maintained in locked files.

Date    __________________________

 

Date Revised    ___________________

 

Staff Person    ____________________

 

Case File Number    _______________

HAVE YOU EVER BEEN HERE BEFORE?
           YES            NO                                  
                                                               

   Housing Information:

   Does your home need repair?    Yes     No

   If Rented,

   How much is your rent?  _______  Per:    Month     Week    Bi-Monthly

   Are utilities included in your rent?    Yes    No

   Subsidized or Public Housing:    Yes   No    If yes, what type?  ___________________

   Type of Housing Rented:    Private    Mobile Home     Apartment     Rented Room    Subsidized Housing

   Information n Landlord

 

   Name:  ___________________________________

 

   Address:  _________________________________    City:  ________________    Zip:  ____________    County:  ___________

 

   Phone:  (_____)____________________________

   If you own the house,

   Type of Housing owned:    Private Home     Mobile Home Amount of Mortgage:________

1.    Is any member of the Household an U.S. Citizen or a Legal Alien?    Yes   No

2.        Has anyone in the Household been granted a legalized resident status under section A or 210A of the immigration and Reform Control Act

3.       If yes, in what year?  ________________  And how many members in the family?  __________

   Does anyone in the Household Receive-

1. Any Income              4. Soc. Security                                      7. SSI Benefits                         10. TEA/TANF              

2. VA Benefits               5. Unemployment Benefits                       8. Food Stamps                     11. GeneralAssistance  

3. Pension                       6. Employment + any other                 9. Employment Only               12. Other                       

Type of Air Conditioning Used:                                                   Types of Heaters Used:

Window Unit      Central Unit                            Space Heaters    Central Heat   Wall Furnace     Electric Heater      

Evaporative Cooler       None                              Fire Place       Wood Burning Stove       Others       None 

INTAKE/FAMILY PROFILE

Intake/Family Profile

FAMILY COMPOSITION

 

1. Head of Household:  Name:  Last________________________  First________________________  SS#_____________________

Race:  White  Black Hispanic  Native American Asian/Pacific Hawaiian Multi-Race Other

 

Mailing Address:  __________________________________  City/Zip: _______________________________________

 

                 County:  ________________________________

 

Residential Address:  _______________________________  City/Zip:_________________________________________

 

                 County:  ________________________________

 

Home Phone:  (_____)___________________________  Work Phone:  (_____)_________________________________

 

Household Type: Single Parent Female Single Parent Male  2 Parent HH  Single Person HH 2 Adults/No Children HH Other

Housing Type: Own/Buying   Rent    Homeless     Other

Characteristics:  Homeless  Farmer   Migrant Farmer    Seasonal Farm worker     Pregnant Youth

Was any Weatherization Service received in the past?  Yes    No     If yes, when?__________________________

Member #6  Name:  _____________________    SS#  _______________________                Race:  __________

Relationship to Head of Household  __________    Sex  _____________ Ethnicity: Hispanic/Latino    Not Hispanic

                            Age  _______    Date of Birth  __________________    Income from 1st Job  __________  Per  ____________

                                                                                                                     Income from 2nd Job  __________  Per  ____________

                                                                                                                     Unearned Income  ____________  Per  ____________

What type of unearned income do you receive?  _____________________________________________  Total  ___________

Disabled      Health Insurance     Veteran 

Education-  0-8      9-12/non grad.    High School Diploma or GED     12 +Some Post Secondary  2 or 4 years college 

Member #3  Name:  ___________________________________    SS#  _______________________                Race:  __________

 Relationship to Head of Household  ______________________    Sex  _____________ Ethnicity: Hispanic/Latino    Not Hispanic

                             Age  _______    Date of Birth  __________________    Income from 1st Job  __________  Per  ____________

                                                                                                                       Income from 2nd Job  __________  Per  ____________

                                                                                                                       Unearned Income  ____________  Per  ____________

What type of unearned income do you receive?  _______________________________________________  Total  ___________

 Disabled      Health Insurance     Veteran 

 Education-  0-8    9-12/non grad.     High School Diploma or GED      12 +Some Post Secondary  2 or 4 years college 

Member #2  Name:  ___________________________________    SS#  _______________________                Race:  __________

 Relationship to Head of Household  _______________________    Sex  _____________ Ethnicity: Hispanic/Latino    Not Hispanic

                             Age  _______    Date of Birth  __________________    Income from 1st Job  __________  Per  ____________

                                                                                                                       Income from 2nd Job  __________  Per  ____________

                                                                                                                       Unearned Income  ____________  Per  ____________

What type of unearned income do you receive?  ________________________________________________  Total  ___________

 Disabled      Health Insurance       Veteran 

 Education-  0-8     9-12/non grad.     High School Diploma or GED     12 +Some Post Secondary     2 or 4 years college 

 

 

Family Information-Head of Household (Customer)

Member #1  Name:  _____________________________________    SS#  _______________________            Race:  __________

Relationship to Head of Household  _______Self_______________    Sex  _____________ Ethnicity: Hispanic/Latino    Not Hispanic

                             Age  _______    Date of Birth  __________________    Income from 1st Job  __________  Per  ____________

                                                                                                                       Income from 2nd Job  __________  Per  ____________

                                                                                                                       Unearned Income  ____________  Per  ____________

What type of unearned income do you receive?  ________________________________________________  Total  ___________

 Disabled      Health Insurance       Veteran 

 Education-  0-8      9-12/non grad.    High School Diploma or GED     12 +Some Post Secondary   2 or 4 years college 

Member #4  Name:  ___________________________________    SS#  _______________________              Race:  __________

 Relationship to Head of Household  _____________________    Sex  _____________ Ethnicity: Hispanic/Latino    Not Hispanic

                             Age  _______    Date of Birth  __________________    Income from 1st Job  __________  Per  ____________

                                                                                                                       Income from 2nd Job  __________  Per  ____________

                                                                                                                       Unearned Income  ____________  Per  ____________

What type of unearned income do you receive?  _____________________________________________  Total  ___________

 Disabled      Health Insurance      Veteran 

 Education-  0-8     9-12/non grad.    High School Diploma or GED     12 +Some Post Secondary  2 or 4 years college 

Member #5  Name:  ___________________________________    SS#  _______________________                Race:  __________

Relationship to Head of Household  _______________________    Sex  _____________ Ethnicity: Hispanic/Latino    Not Hispanic

                             Age  _______    Date of Birth  __________________    Income from 1st Job  __________  Per  ____________

                                                                                                                       Income from 2nd Job  __________  Per  ____________

                                                                                                                       Unearned Income  ____________  Per  ____________

What type of unearned income do you receive?  ______________________________________________  Total  ___________

Disabled      Health Insurance     Veteran 

Education-  0-8      9-12/non grad.    High School Diploma or GED     12 +Some Post Secondary  2 or 4 years college 

IF YOU NEED ADDITIONAL SPACE OR SERVICES, PLEASE NOTIFY YOUR CASEWORKER.