Emergency Assistance Application Emergency Assistance Inquiry Please complete this form to help us learn about your situation. Additional information will be needed for an assistaance application.Full Name* First Last Date of birth* MM slash DD slash YYYY Last four digits of Social Security number*Gender* Male Female Ethnicity* American Indian or Alaska Native Asian Black/African American Native Hawaiian or other Pacific Islander White Hispanic Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Are you a Veteran? Yes No Are you a U.S. Citizen Yes No Please list the ages of all other adults and children in your household.Your total income in food stamps:Monthly pay from your job:Monthly income from Families First:Monthly income from SSI:Monthly income from retirement:Monthly income from child support:Monthly income from unemployment:Monthly income from other sources:What type of assistance do you need? Utility Rent Mortgage Shelter Food Clothing Utility cutoff date MM slash DD slash YYYY Utility cutoff amountName on utility account First Last Are the lights off now? Yes No Utility account numberIf yes, how long have the lights been off?Monthly rent or mortgage amount:Total past due amount of rent or mortgage:How many months' back rent do you owe?Have you been served an eviction notice? Yes No Eviction date MM slash DD slash YYYY Are you homeless now? Yes No If yes, where did you and your children (if applicable) sleep last night?What emergency in the past 90 days has prevented you from paying your bills? Laid off from work On medical leave without pay Reduction in salary rate Date emergency happened:* MM slash DD slash YYYY Are you currently unemployed?* Yes No How long?*Please provide your employer's name:*I understand the sharing policy of HMIS (see below) and AUTHORIZE the sharing of the additional personal information in HMIS about me and my dependents to be shared with the agencies and licensed users belonging to the West TN HMIS. Yes, I understand "I consent to allow Fayette Cares to share information with cooperating agencies for the purpose of obtaining assistance for me and for auditing, monitoring, reporting, and evaluating purposes. I swear and affirm that the information I have provided is true and correct."* I agree I do not agree
