River of Hope 2021 Application
Please fill out for COMPLETELY!! If you do not hear from us with in 24 hours, email us at Riverofhopetx@gmail.com
Answer each question then submit when complete
First Name *
Last Name *
Address *
City & Zip Code *
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Female: Pregnant *
Marital Status *
Education *
Race *
Alternative Contact: Name, Phone & Relation *
U.S, Military Active or Veteran *
Housing Status *
Disability Type (HEAD OF HOUSE ONLY) *
Is your Disability of Long Duration *
Health (HEAD OF HOUSEHOLD ONLY) *
Who lives in your Household; Name, Date of Birth and Relation to you *
Current Monthly income *
Income From *
Are you currently on any other Rental Assistance Program? *
Do Receive Food Stamps? If YES, How much? *
How much is Rent? *
How much does your Electric run? *
How much does your water bill run? *
How much does you Natural Gas run? *
Do you PAY or RECEIVE Child Support, if YES, How much and how often? *
How much does your Telephone bill run? *
How much does you Cable run? *
How much does your Car insurance run? *
How much does you Car payment run? *
Have you Received any other Assistance with your Rent or Utility Bills? If YES, Please list Date assisted, What Agency and What type of Assistance. *
If Lost your Employment or Hours cut due to COVID-19, Have you applied for Unemployment? *
What type of Assistance are you seeking? *
DESCRIBE YOUR SITUATION: WHAT CAUSED YOU TO SEEK ASSISTANCE? PLEASE DO NOTREPLY, "I NNEDHELP" WE NEED TO KNOW YOUR CRISIS? *
I hear by authorize River of Hope to receive, from any and all Sources, and to release to any person of another organization confidential information regarding client which may be necessary of useful to River of Hope in relation to the services to be rendered except medical information. I hereby release River of Hope from all liability in anyway related to the receipt and/or release of said confidential information. *
I understand the release of this information does not guarantee that assistance will be provided but, that without information, my case cannot be in consideration of the services to undertaken or rendered considered by River of Hope. *
Required
Email Address *
Phone Number *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy