Application.htm

Fairgrove Family Resource Center Application for Services Please print
PROOF OF ADDRESS & INCOME, PHOTO ID AND SOCIAL SECURITY CARD ARE REQUIRED

Name:				Phone:		Date:
							How long have
Address:				City:			you lived there?

Do you own or rent?		Landlord Name or Mortgage Co.
Landlord Address:			City:			Phone:


HOW MANY PEOPLE LIVE IN YOUR HOUSE?				# disabled:		# working:
Please list all persons in household. Be sure to list everyone and all their information.
Realtionship / Name		Age	Race	Sex	Social Security #	Date of Birth		ID #
Self
Spouse
Child
Child
Child
Child
Child
Parent/Other

LIST ALL MONTHLY INCOME			Employer Name		Phone Number	$$Monthly Expenses$$
Employment		$				Rent or Mortgage		$
Work 1st /AFDC		$				Lot Rent		$
Disability		$	Hourly Rate		Hours Worked	Electric		$
Disability		$				Gas/Heat		$
Social Security		$	$			Car Payment		$
Unemployment		$				Auto Insurance		$
Child Support		$	Spouse's Employer		Phone Number	Cable/Satelite		$
Food Stamps		$				Home phone bill		$
Government Energy Check		$				Cell phone bill		$
Income Tax Refund		$	Hourly Rate		Hours Worked	Water		$
Other		$				Child Support		$
Other		$	$			Credit Cards		$
TOTAL		$				Property Taxes		$
						Child Care		$
	Nature of Request (circle all that apply)					Medication		$
Food		Electricity		Kerosene		Rent to own		$
Heating oil		Water		Rent		Life Insurance		$
						TOTAL		$
Reason for request?


I certify the above information is correct and make application to Fairgrove Family Resource Center for assistance
I give permission to Fairgrove FRC to make any inquires to confirm above information and need for assistance.

X
Signature						Date
Date Commitment called in:						Amount$
Vendor Contact:						Check #
Vendor:		Address:				Date Paid

Need $		Client $			FGFRC $		DCCA $
CCM $		S. ARMY $			DSS $		CHURCH $

Name on Bill:			Account Number:				Grant used: