Outreach Assistance Applic
If requested by you form may be faxed to other organizations, write clearly using a dark pen.
ID Required .
C Complete Entire Form D
Please Print: New: Repe
(Last) (First) (M.I.)
(City) (State) (Zip)
(Phone) Home Cell Work
DOB: . Sex: M F (circle on) Age: .
# of Adults in Household . # of Children in Household .
List All Household Members:
Name: Sex: Age: Relationship .
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: .
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 wh
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:
Have you been to CHAP or MEAP? Yes No (circle one)
If Yes, wh
Do you have a shut off notice? Yes No (circle one)
I have given the CCEA
staff permission for this inform
The completed form can be faxed to (866)922-6674 or
email to firstname.lastname@example.org
Would you like to be contacted by a Pastor or Deacon? Religion: .