Chesapeake City Ecumenical Association (CCEA)

Outreach Assistance Application

If requested by you form may be faxed to other organizations, write clearly using a dark pen.

ID Required . C Complete Entire Form Date: .

Please Print: New: Repeat: .

Name: .

(Last) (First) (M.I.)

Address: .

(Street)

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(City) (State) (Zip)

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(Phone) Home Cell Work

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Email Address

DOB: . Sex: M F (circle on) Age: .

# of Adults in Household . # of Children in Household .

List All Household Members:

Name: Sex: Age: Relationship .

1. .

2. .

3. .

4. .

5. .

6. .

7. .

8. .

9. .

Referred by: . Phone #: .

Income: (Monthly Average) Expense: (Monthly Average)

Employment Self: . Rent/Mortgage: .

(Employer) . Water/Sewer: .

Spouse/Partner: . Electric/Gas: .

(Employer) . Heat/Oil: .

AFDC) . Daycare: .

Food Stamps: . Monthly Food Bill: .

Social Security: . Phone: .

Disability: . Other: .

Unemployment: .

Pension: .

Income from other

Family members .

Other sources .

Total Income: . Total Expenses: .

(CONTINUED ON OTHER SIDE)

Type of assistance needed: .

Include Copy Of Invoice

Reason for assistance: .

Have you been to Social Services Yes No (circle one)

If Yes what is the status? .

If requesting Food: Check items you have:

Microwave Oven Refrigerator Coffee Maker .

If requesting Rental Assistance:

Name of Landlord: .

Address of Landlord: .

Phone # of Landlord: .

Fax # of Landlord: .

Do you have an eviction notice? Yes No (circle one)

If requesting Electric or Fuel:

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Have you been to CHAP or MEAP? Yes No (circle one)

If Yes, what is the status? .

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Do you have a shut off notice? Yes No (circle one)

What other commitments for funds from other agencies have you obtained? .

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Information contained in this application is TRUE* to the best of my knowledge.

I have given the CCEA staff permission for this information to be verified.

* Declaration under Penalty and Perjury

The completed form can be faxed to (866)922-6674 or

email to outreach@ccea4u.com

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Signature Date

Optional information: Are you affiliated with a church, if so which one: .

Would you like to be contacted by a Pastor or Deacon? Religion: .

Information contained in this application is sensitive and

For Official Use Only by the CCEA staff.

DB

Check/CC issued

Quicken

Letter Mailed/Faxed

Outreach Coordinator: .