Family Assistance Application, Self-Declaration of Income, ROI

Date Completing Application: (MM/DD/YYYY) * +

Family Services Program Application

To be completed by applicant

Please type NA in all fields that do not apply to you and your family.

Name: *

Address: *

Email that is checked regularly: *

Best Phone Number: *

Marital Status: *

Race, Ethnicity: *

Are you Hispanic or Latino origin? *

Education: *

What is the nature of the assistance being requested? Check all that apply. *

If you are requesting Formula, please state what kind. If you are requesting Diapers, please specify size. Enter NA if not applicable to your situation.

Homeless and in need of housing: *

If you are homeless; where are you staying? *

Please describe your current situation: *

Applicant Confirmation - Please Read and Sign

I understand that this application may not be processed without providing the following documents:

30 days/proof of all household income

Housing documents (Lease/Mortgage)

Photo ID

All household bills/bank statements

Documentation of situation (expense receipts, hospital bills, court papers)

I understand that each funding source may have eligibility requirements as well requirements regarding the amount and frequency of assistance. Catholic Charities of Ashtabula County must adhere to those restrictions. Providing false information will automatically disqualify this application.

Applicant Signature: *

clear

Date: (MM/DD/YYYY) * +

Does anyone else live with you full time? *

How many people live in your household full time? *

Please answer the following completely for each member of your household that lives with you full time.