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Family Promise of Juneau Inquiry Form
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* Indicates required question
*
MM
/
DD
/
YYYY
Adult 1 Name
*
Your answer
Adult 1 Race
*
Your answer
Adult 1 DOB
*
MM
/
DD
/
YYYY
Adult 1 Phone number
*
Your answer
Adult 2 Name
Your answer
Adult 2 Race
Your answer
Adult 2 DOB
MM
/
DD
/
YYYY
Adult 2 Phone number
Your answer
Employment for Adult 1
Your answer
Income for Adult 1
Your answer
Employment for Adult 2
Your answer
Income for Adult 2
Your answer
Criminal History for Adult 1
Your answer
Drug Use for Adult 1
Your answer
Criminal History for Adult 2
Your answer
Drug Use for Adult 2
Your answer
Existing Services
*
Temporary Assistance to Native Families (TANF)
Alaska Temporary Assistance Program (ATAP)
Women Infants and Children (WIC)
Food Stamps (SNAP)
Tlingit and Haida (T&H)
Medicaid
Denali Medical Care
Health Insurance
Work Program
Transportation Assistance
Clothing Assistance
Section 8 Housing Voucher
Other:
Required
Do you have minor children that live with you?
*
Yes
No
What type of assistance are you seeking?
Your answer
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