CVHWA Grant Funding Application

First Name *

Middle Initial

Last Name *

SSN *

Date of birth * +

Age *

Gender *

Male

Female

Street Address *

Address Line 2

City *

State *

Zip Code *

What is the preferred number to reach you at? *

Phone Number *

Would you like to add another contact number? *

Yes

No

Phone Number

Best time to call *

7:30 - 9:00

9:00 - 12:00

12:00 - 3:00

3:00 - 5:00

Email Address *

Emergency contact information

	Name	Phone number	Relationship
1	Name	Phone number	Relationship
2	Name	Phone number	Relationship

Marital and Living Status Information

What is your Martial Status *

Choose the one below that best describes your living situation *

Spouse/Domestic Partner's First and Last Name

Spouse/Domestic Partner's Date of Birth

Spouse/Domestic Partner's Employer

How many adults (over 18 years of age) are in your home? *

How many children (under 18 years of age) are in your home? *

Name, Date of Birth, and Relationship of EVERYONE living in the home Example: John Smith, 07/17/1967, Roommate or Jane Smith, 05/23/2011, Daughter. Do not include yourself.

	Name	Date of Birth	Relationship
1	Name	Date of Birth	Relationship
2	Name	Date of Birth	Relationship
3	Name	Date of Birth	Relationship
4	Name	Date of Birth	Relationship
5	Name	Date of Birth	Relationship
6	Name	Date of Birth	Relationship

Financial Information

Your MONTHLY net income *

Spouse/Domestic Partner's MONTHLY net income

Which best describes your housing situation *

Own	Rent
Other (please explain) Other (please explain)

Monthly Rent/Mortgage *

Check all that apply to your current financial situation:

Check all that apply to your alternative sources of income:

I receive Child Support	I receive alimony
I receive a monthly inheritance	I receive unemployment benefits
I receive disability payments	I receive Social Security
I receive public assistance (welfare, food stamps, etc.)

Unemployment benefits amount received monthly

Child support amount received monthly

Alimony amount received monthly

Public assistance received monthly

Please provide a short explanation for the request for financial support (why you cannot afford the cost of care). 🛈

Required Documentation (PDF Format) Please black out all occurrences of account numbers and/or SSN

Copy of ID

Last two pay stubs

All pages of your latest federal tax return for all members of your household

Copies of your last bank statement for all member of your household from all of your bank accounts

If you are unemployed: a copy of your SSI or SSDI Benefit Letter, proof of any federal or state assistance, unemployment benefits letter.

If you are receiving military service-connected disability, a copy of your award letter from the Department of Veterans Affairs

Acknowledgement and Signature

By signing this form, you agree that you are willing to be seen by a provider at the Family Care Center and will become a client of this clinic upon submission of this form. Two or more no-shows for an initial appointment can result in you not being accepted as a client. *

clear

I pay Child Support	I pay alimony
Recent job loss	Senior Citizen
Permanently Disabled (SSDI)	Temporarily Disabled (SSI)