232-HELP Preliminary Application

Date:_______________ Applicant Name:______________________________________

Address:_________________________________________________________________

City:_________________________________    State:___________    Zip:_____________

Phone Number:_______________________   Number in Household:____________

Marital Status (circle one):      Married      Single      Divorced      Widowed

Date of Birth:________________     Social Security Num.:_________________________

Ethnicity (circle one):  White    African American    Hispanic      Asian      American Indian

List All People Living in Household (including applicant)

Full Name                                     Age       Relationship        Income           Source of Income

_________________________   ______    __________     $_________     ________________

_________________________   ______    __________     $_________     ________________

_________________________   ______    __________     $_________     ________________

_________________________   ______    __________     $_________     ________________

_________________________   ______    __________     $_________     ________________

_________________________   ______    __________     $_________     ________________

(If you need more space, use the back of the page)

Do you receive Food Stamps (circle one)?   Yes  /  No

If yes, how much do you receive?$____________________
 

Program Applying For (please check one):

____  Donated Dental Service

____  Medical Appliance Loan Program

____  Eye Care for the Needy

____  Milk Fund

____  HelpLine

____  Low Cost Blood Level Testing

____  Transportation

A brief statement to as why you need services:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________
 
 
 
 

___________________________________________                    _____________________
Applicant's Signature                                                                          Date
 
 
 

If application submitted by a third party:
 

____________________________________                    ______________________
Contact Name                                                                     Phone Number
 

____________________________________
Name of Agency