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Application for assistance
I. BASIC INFORMATION
Full Name (First, Middle, Last of applicant or authorized person)
Identification Number (if known)
Residential Address (Street, City, Postal Code)
Primary Phone Number (home or preferred)
Mailing Address (if different: Street, City, Postal Code)
Additional Phone Number(s) (if any)
II. HOUSEHOLD DETAILS
Check all that apply:
Unable to work due to health condition
Has a disability
Pregnant (Enter due date below)
Pregnancy Due Date (if applicable)
Expected Household Income This Month (UAH)
Cash + Bank Balances (UAH)
Housing Costs (rent or mortgage) (UAH)
Utilities Paid (Heating, Phone, Other - specify)
Is anyone in the household a seasonal or migrant farmworker?
Yes
No
How many people do you buy and cook food for?
III. SPECIAL NEEDS
Phone Number for Interview Request
Language You Speak (or sign language)
Language for Letters (if translation needed)
IV. FAMILY MEMBERS
Full Name, Gender (Male / Female), Relationship to Applicant, Date of Birth, Social Security Number, Citizen of Ukraine? (Yes / No)
V. ADDITIONAL BACKGROUND
Hispanic/Latino Ethnicity?
Yes
No
Received aid from another region/agency in past 30 days?
Yes
No
If Yes – From Whom?
Anyone lives outside Ukraine?
Yes
No
Anyone sponsored as foreigner?
Yes
No
Anyone currently studying?
Yes
No
If Yes – Who?
Anyone temporarily absent from household?
Yes
No
If Yes – Who?
Served in military?
Yes
No
Dependent/spouse of veteran?
Yes
No
Evading legal authorities?
Yes
No
Living situation:
Own house
Group home
Institution
Other
Date moved into current residence (if in institution)
Month
Day
Year
Marital Status
Single
Married
Divorced
Widowed
Separated
VI. HEALTH INFORMATION
Anyone recently lived in or returned from medical facility?
Yes
No
VII. RESOURCES
List of assets (owner, location, value)
List of vehicles (year, make, model, leased?, used for medical?)
Transferred/sold property in last 5 years?
Yes
No
If Yes – What and When?
VIII. EARNED INCOME
Anyone stopped working in last 60 days?
Yes
No
Anyone has earned income?
Yes
No
For each person: Full Name, Employer Phone, Start Date, Self-employed (Yes/No), Gross Income (UAH), Frequency (weekly/biweekly/monthly), Weekly hours, Pay dates
IX. OTHER INCOME
List of other income: Social Security, Child/Spouse Support, Pension, VA/Military benefits, Trusts, Rent, Investments, Other (amount + recipient)
X. ANNUITIES
Annuities (owner, organization, value, monthly income, purchase date)
XI. MONTHLY EXPENSES
Rent / Mortgage / Condo Fee (UAH)
Property Insurance / Taxes (UAH)
Does anyone help you pay these?
Yes
No
If Yes – Who, Which Expenses, Amount Paid
Child/Adult care expenses (UAH)
Medical costs for disabled or 60+ (UAH)
Child support paid (UAH)
Submit
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ABOUT US
PARTNERS
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GALLERY
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FOR VOLUNTEERS
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