Braes Interfaith Ministries Client Data
Please note that to be served you must have:
1.) Current Proof of residence (for Example Current rent receipt or utility bill.)
2.) Original Social Security Card or Birth Certificate for every member of your household.
3.) Picture I.D. For yourself.

An interviewer will check the information. Please have it available.
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Today's Date *
MM
/
DD
/
YYYY
Name *
Address *
Apt#
Phone Number *
Zip Code *
Other Zip Code
Type of assistance needed: *
Have you been here before? *
Head of house hold (You) *
Employment Status? *
Number in House Hold - White *
Are you homeless? *
Number in House Hold - Black *
Number in House Hold - Hispanic *
Number in House Hold - Asian *
Number in House Hold - Other *
Number in Household by Age Group *
0-5 Years?
Name(s), Age, Relationship to Client *
Number in Household by Age Group *
6-9 Years?
Name(s), Age, Relationship to Client
Number in Household by Age Group *
10-17 Years Old?
Name(s), Age, Relationship to Client
Number in Household by Age Group *
18-29 Years Old?
Name(s), Age, Relationship to Client
Number in Household by Age Group *
30-39 Years Old?
Name(s), Age, Relationship to Client
Number in Household by Age Group
40-49 Years Old?
Name(s), Age, Relationship to Client
Number in Household by Age Group *
50-59 Years Old?
Name(s), Age, Relationship to Client
Number in Household by Age Group *
60-64 Years Old?
Name(s), Age, Relationship to Client
Number in Household by Age Group *
65+ Years Old?
Name(s), Age, Relationship to Client
For Official Use Only
Please give computer back to your interviewer
Assistance Received? Check ALL That Apply *
Required
Food *
Comments
Consent Form Signed *
Required
Verification of Food Received *
Interviewers Name
Clients Name Receiving Food *
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