Gather Application for Assistance

 

Last Name:____________________

First Name: ____________________

Middle Initial:____________________

Address___________________________________Phone:_____________________________

City:___________________________State:________________________

Zip___________________________Date of Birth:_________________________

Head of Household: Yes:____ No:____
No. of Dependents: _________________________________

Email address:_____________________________________

Work Phone: _________________________________

Cell or Msg Phone:__________________________________

Employer: Disability: Yes:____ No: ____ Veteran: Yes: ____No:_________

 

Applicant Household Members - List ALL people living at this address.

Name:___________________________Relationship:_______________________DOB:_____________ __

Disability: Yes:____ No:____ Veteran: yes:____ No:____ Employed: Yes:____ No:____

Name:___________________________Relationship:_______________________DOB:_____________ __

Disability: Yes:____ No:____ Veteran: Yes:____ No:____ Employed: Yes:____ No:____

Name:___________________________Relationship:_______________________DOB:_______________

Disability: Yes:____ No:____ Veteran: Yes:____ No:____ Employed: Yes:____ No:____

Name:___________________________Relationship:_______________________DOB:_____________ __

Disability: Yes:____ No:____ Veteran: Yes:____ No:____ Employed: Yes:____ No:____

Name:___________________________Relationship:_______________________DOB:_______________

Disability: Yes:____ No:____ Veteran: Yes:____ No:____ Employed: Yes:____No:____

Name:___________________________Relationship:_______________________DOB:_______________

Disability: Yes:____ No:____ Veteran: Yes:____ No: Employed: Yes:____ No:____

 

By signing this application I:

  1. CertifythattheinformationIhaveprovidedistrueandcompletetothebestofmyknowledgeand provides an accurate summary of my situation.  Please initial here: _______________

  2. Understandthatstatisticalinformationonthisapplicationwhichisconfidentialastospecific identities will not be shared with other agencies but may be used as
    needed to request funding in grants or as part of an audit or application. Please initial here: ____________