Intake Form with Documentation
  • Instructions
  • Primary Applicant Information
  • Household Information
  • Education & Demographics
  • Requested Services
    • Signature

    Before you get started, please gather the following information for each member of your household. This information must be uploaded to complete the intake application.

    Each household member OVER the age of 20 must upload current proof of monthly income or proof of no income. See the list below for acceptable proofs:

    • Check stubs showing gross amount (current within the last 30 days)
    • Verification of Employment statement with expected salary details
    • Unemployment benefit letter
    • DHHS paperwork stating monthly income for household (current within the year requesting assistance)
    • Pension benefit letter
    • Social Security benefit letter
    • Child Support payment history or court paperwork with awarded amount listed
    • Proof of no income: HUD lease or proof of subsidized housing residency, termination of employment letter, or letter certifying zero income from DHHS, Ministry With Community, Gospel Mission, or similar partnering agency caseworker.

    Additionally, each household member OVER the age of 20 must upload current proof of residency. See the list below for acceptable proofs:

    • Current bill or official mail (dated within last 30 days) with name and address
    • Any of the income verification documents listed above that also include current address
    • DHHS paperwork with family members listed at current mailing address (current within the year requesting assistance) If multiple addresses are present on income and residency documents, additional proofs may be required.

    For each household member UNDER the age of 21, please upload any of the following:

    • Social Security Card
    • Birth Certificate
    • Medicaid/Medical Insurance card
    • DHHS paperwork with family members listed (current within the year requesting assistance)
    If you would prefer to download a pdf of the form, please click here. Print and fill out the form and bring it, with the required proofs, to our office.