C3 COMMUNITY CARE APPLICATION

Name

First Name

Last Name

Age

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Marital Status

Employer

Yes

Employed Since

Date of employment

Combined Household Income (for the household, per month)

Income from Jobs

Hourly Wage/Hours Per Week

Child Support Received

SSI/SSDI Income

Unemployment

FoodShare

Other Income

Expenses/Debt (for the household, per month)

Rent

Utilities

Medical Insurance

Auto Insurance

Student Loans

Cable/Internet

Auto Loans

Cell Phone

Medical Debt

Credit Card Debt

Mortgage

Other Expenses/Debt

List all other persons living in the household (include name, date of birth, and relationship)

Name of Your Home Church

How long have you attended?

How did you hear about C3's Community Care Program?

Where else have you requested assistance?

Please describe your current situation and the reason for your request:

How can we assist you?

Have you previously received assistance from C3?

Yes

Landlord Name (if request is for rent)

First Name

Last Name

Landlord Phone #

(###)

###

####

NOTE: Requests for rent will be required to return the "Notice of Rent Due" form.

By signing, I am stating that the information I have provided is true and accurate. The C3 Community Care team has my permission to verify any information that I have reported on this application.

Applicant Digital Signature