Client Documentation Information Request Form

Name

Nombre

Apellido

E-mail

Phone Number

Why are you no longer employed?

Why don't you have a money order this week?

Not paid yet Lost it Other

Money Order Date

Money Order Amount

Picture of Money Order

Max 10 MB per file

Why don't you have a copy of your paycheck this week?

Not paid yet Lost it Other

Paycheck Date

Paycheck Amount

Picture of Paycheck

Max 10 MB per file

Why don't you have a copy of your bank statement this week?

Not available Lost it Other

Bank Statement Date

Bank Statement Amount

Picture of Bank Statement

Max 10 MB per file

Why don't you have a copy of your rent receipt?

Not available Lost it Other

Rent Receipt Date

Rent Receipt Amount

Picture of Rent Receipt

Max 10 MB per file

What monthly expenses have you paid this month?

Are you having issues with housing/landlord?

Yes, eviction notice Yes, repairs needed Yes, dispute with landlord No

Rate your housing experience

What are your current goals?

Find employment Stable housing Financial assistance Education or training Childcare assistance

How can we help you with your goals?

When do you need to re-certify for ELC/Daycare?

Did any family challenges occur this week?

Yes No

Signature

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