North Ridgeville Community Care                      Client Application
To be eligible for all programs at North Ridgeville Community Care this calendar year, please complete and submit the following application with as much information as possible about your household.  
To continue as a client of North Ridgeville Community Care, current clients must renew their applications each year.

If you are in immediate need of food for your household, visit us during our food distribution hours and bring your photo ID. We are located directly behind Arby's on Center Ridge Rd. in North Ridgeville, Ohio.

Food Distribution Hours:
Mondays & Tuesdays 9:30 AM - 1:30 PM
Thursdays 3:00 PM - 6:00 PM

*If your utilities have been disconnected, submit this application and contact us immediately by calling (440) 353-9716 in order to be considered for immediate financial assistance. You will receive an email after you submit this application requesting the required eligibility documents for eligibility.

If your utilities are not currently disconnected, you may apply for financial assistance 30 days after your application and all eligibility documents have been received and approved. 
Sign in to Google to save your progress. Learn more
What is your Client Number? (List only the first 3 digits)  
Skip this question if you don't have a previously assigned client number. 
How did you hear about Community Care? Are you currently a client? Were you in the past? Did you hear about us from a friend or online?  Etc. *
Last Name *
First Name *
Phone number (###) ###-####
(please DOUBLE-CHECK that it is typed correctly, we will contact you using this phone number)
Can you receive texts? *
Email Address (Double check that your email address is typed correctly. We will use this email address to contact you with important information and follow-up eligibility documents)
Do you live in North Ridgeville, Ohio? *
What is your street address? *
Do you own or rent your home? *
What is your monthly rent or mortgage payment? *
How many total people are currently in your household? *
List everyone in your household (including yourself), their relationship to you, their date of birth, current age, sex,  Example:                                                                                                                                                                                                                              Jane Doe, Self, 12/1/1980, Age 40, female (Click ENTER after each to add a new line per person)                                                                                                                                                                           *
HOUSEHOLD INCOME - Include wages from employment, retirement/pension, social security, child support, etc., for members of your household.
EMPLOYMENT: For your household, list everyone who is employed, where they are employed at, and how much their monthly pay is BEFORE taxes. (Click ENTER after each to add a new line per person)
SOCIAL SECURITY: For your household, list anyone who receives Social Security, and how much is received monthly BEFORE deductions.- (Click ENTER after each to add a new line per person)
RETIREMENT / PENSION: For your household, list anyone who receives a monthly pension and how much is received monthly. (Click ENTER after each to add a new line per person)
CHILD SUPPORT: For your household, list anyone who receives child support payments and how much is received monthly. Are the child support payments current? (Click ENTER after each to add a new line per person)
OTHER INCOME: For your household, list anyone who receives any other income not listed above. Include any income that is not taxed/ "under the table." (Click ENTER after each to add a new line per person)
SNAP (FOOD STAMPS): For anyone in your household who receives SNAP benefits, list the monthly amount.
Please briefly explain your situation and what has led you to seek or continue seeking services from Community Care. *
After you submit this form, we will contact you using the email address provided and send instructions for submitting application eligibility documents through email or in person. If no email address is provided, we will contact you by phone. 

Application documents needed:
Photo ID - for all adults in the household
Social Security cards - for everyone in the household
Birth Certificates - for all children in the household 
Residency - a current utility bill
Proof of Income - paystubs/Social Security letter, etc.
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy