Intake Form

NOTE: By completing this form, you are submitting an Intake Form to the Warren Township Trustee of Marion County. Please submit only one (1) application per thirty (30) day period. Duplicate applications within a thirty (30) day period will be automatically deleted from our system. You may expect a response time of 7-10 days. Thank you for your patience.

Have you completed this form within the last thirty (30 days? *

• Yes
• No

IF YOU ANSWERED YES ABOVE STOP HERE

Are you a United States citizen? *

• Yes
• No
• Qualified Alien (as defined under 8 U.S.C. 1641)
• Someone in my household adult(s) or child(ren) is not a US citizen or Qualified Alien

Months/Years to Where

Are you a resident of Warren Township? *

• Yes
• No
• Not sure

TOTAL HOUSEHOLD MEMBERS *

# of Adults in Household *

Client Name *

First

Last

Client Date of Birth *

Adult #2

First

Last

Date of Birth

Adult #3

First

Last

Date of Birth

Are any of the adults listed, age 18 or older, currently enrolled in high school? *

• Yes
• No

NUMBER OF CHILDREN AGED 17 AND YOUNGER *

Ages of each child 17 and younger *

Client Street Address *

Apt

City *

State *

Zip Code *

Client Telephone Number *

Client Email Address *

Re-enter Client Email Address *

Do you receive government housing assistance (i.e. Section 8, Public/Low Income Housing, HUD, Section 42)? *

• Yes - Section 8
• Yes - Public/Low Income Housing
• No

Months/Years lived at this address *

What month(s) of rent do you currently owe? *

Are you currently in the court eviction process? *

• Yes
• No

Court Date (If Applicable):

How much is your base rent? (Monthly) *

How many bedrooms are in your home? *

LANDLORD/MORTGAGE COMPANY/PROPERTY MANAGEMENT NAME *

ASSISTANCE AND CIRCUMSTANCE What type of assistance are you seeking? (Select all that apply) *

• Housing Assistance - Rent/Mortgage
• Emergency Shelter
• Utility
• Clothing
• Diapers
• Bus Pass
• Household Items
• Food
• Burial or Cremation
• Eligible Medical Services
• Other

If you chose other, please explain.

Please describe the events that have taken place in the past 90 days resulting in your household's need for emergency assistance. *

EMPLOYMENT HISTORY What is your current employment status? *

• Employed Full Time
• Employed Part Time
• Unemployed
• Student
• Retired
• Self Employed
• Receiving Unemployment
• PRN (as needed)
• Receiving Social Security
• Receiving Disability
• Seasonl/Temporary Position
• Other

ADULT #1 - EMPLOYER NAME

Date Hired *

Employment End Date (if Applicable)

What led to your departure from that job?

Did/Do you receive payment on a weekly, bi-weekly, daily, or per-job basis?

• Weekly
• Bi-Weekly
• Daily
• Per Job

Additionally, we would appreciate it if you could share more about your work history and any challenges you may be facing in your current or past roles.

ADULT #2 - EMPLOYER NAME

Date Hired *

Employment End Date (if Applicable)

What led to your departure from that job?

Did/Do you receive payment on a weekly, bi-weekly, daily, or per-job basis?

• Weekly
• Bi-Weekly
• Daily
• Per Job

Additionally, we would appreciate it if you could share more about your work history and any challenges you may be facing in your current or past roles.

ADULT #3 - EMPLOYER NAME

Date Hired *

Employment End Date (if Applicable)

What led to your departure from that job?

Did/Do you receive payment on a weekly, bi-weekly, daily, or per-job basis?

• Weekly
• Bi-Weekly
• Daily
• Per Job

Additionally, we would appreciate it if you could share more about your work history and any challenges you may be facing in your current or past roles.

Do you need an Interpreter? *

• Spanish
• Haitian - Creole
• ASL
• Other
• No

Would you prefer to receive your appointment details and paperwork by mail or email? If mailed, all required documents will be highlighted in yellow for your convenience. If emailed, please ensure you have access to a printer to print the necessary documents for your appointment. *

• Please email my documents and appointment
• Please mail my documents and appointment
• Please email and mail my documents and appointment

What is your approximate TOTAL monthly income for ALL MEMBERS in the household ? *

Where do you bank? *

Additional Comment or Information

Today's Date *

SUBMIT PRE-INTAKE APPLICATION