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Covering Kids and Families of Indiana (CKF)
COVID-19 Relief Assistance
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Parental Guide to Youth Drug Prevention
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Rental Information
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Members Area
Menu
Home
Services
Family Life
Covering Kids and Families of Indiana (CKF)
COVID-19 Relief Assistance
Early Head Start
Head Start
TALKS (Transferring A Little Knowledge Systematically) Mentoring
WIC – Women, Infants, and Children
Community Resource Directories
Parental Guide to Youth Drug Prevention
Domestic Violence Shelters and Assistance
Resources for Veterans, Disabled, and Mental Illness
Housing
Rental Properties
Rental Information
Rental Application
Income Certification Questionnaire
View All Properties
Rental Assistance
Lead Paint Testing
Weatherization
Energy Assistance
Financial Planning
Small Business Loans
Indiana Foreclosure Prevention Network
Homeownership Education and Counseling Program
Elder Adults
Money Management
Volunteer Income Tax Assistance
News
About
FAQs
Make a Donation
Board of Directors
Employment Opportunities
Annual Reports, Audit Results, and 990 Forms
Customer Satisfaction Survey and Community Needs Assessment
Joan E. Cline Memorial Scholarship
Locations
Contact
Members Area
Home
Services
Family Life
Covering Kids and Families of Indiana (CKF)
COVID-19 Relief Assistance
Early Head Start
Head Start
TALKS (Transferring A Little Knowledge Systematically) Mentoring
WIC – Women, Infants, and Children
Community Resource Directories
Parental Guide to Youth Drug Prevention
Domestic Violence Shelters and Assistance
Resources for Veterans, Disabled, and Mental Illness
Housing
Rental Properties
Rental Information
Rental Application
Income Certification Questionnaire
View All Properties
Rental Assistance
Lead Paint Testing
Weatherization
Energy Assistance
Financial Planning
Small Business Loans
Indiana Foreclosure Prevention Network
Homeownership Education and Counseling Program
Elder Adults
Money Management
Volunteer Income Tax Assistance
News
About
FAQs
Make a Donation
Board of Directors
Employment Opportunities
Annual Reports, Audit Results, and 990 Forms
Customer Satisfaction Survey and Community Needs Assessment
Joan E. Cline Memorial Scholarship
Locations
Contact
Members Area
Menu
Home
Services
Family Life
Covering Kids and Families of Indiana (CKF)
COVID-19 Relief Assistance
Early Head Start
Head Start
TALKS (Transferring A Little Knowledge Systematically) Mentoring
WIC – Women, Infants, and Children
Community Resource Directories
Parental Guide to Youth Drug Prevention
Domestic Violence Shelters and Assistance
Resources for Veterans, Disabled, and Mental Illness
Housing
Rental Properties
Rental Information
Rental Application
Income Certification Questionnaire
View All Properties
Rental Assistance
Lead Paint Testing
Weatherization
Energy Assistance
Financial Planning
Small Business Loans
Indiana Foreclosure Prevention Network
Homeownership Education and Counseling Program
Elder Adults
Money Management
Volunteer Income Tax Assistance
News
About
FAQs
Make a Donation
Board of Directors
Employment Opportunities
Annual Reports, Audit Results, and 990 Forms
Customer Satisfaction Survey and Community Needs Assessment
Joan E. Cline Memorial Scholarship
Locations
Contact
Members Area
Application
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ZIP Code
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*
Different Mailing Address?
Yes
Alternate Mailing Address, if different from physical
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
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Delaware
District of Columbia
Florida
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Armed Forces Pacific
State
ZIP Code
County
*
Phone Number
*
May we text you?
*
Yes
No
E-mail Address
May we E-mail you?
Yes
No
Indicate needed assistance (check all that apply):
*
Rental Payment
Mortgage Payment
Utility Payment
Childcare Payments
Mental Health Copay
Food Assistance
Other Emergency
Other Emergency Information
*
Home Ownership Type
*
Own
Rent
Other
Other Ownership Type
*
Renters: Do you receive subsidized housing vouchers?
*
Yes
No
Did you have earned income prior to the stay-at-home order?
*
Yes
No
Total Annual Income
*
Please indicate your total annual income from all income sources.
Do you qualify for unemployment insurance?
*
Yes
No
Household Members
Please list all people residing at this address
How many household members do you have?
*
Please select »
1
2
3
4
5
6
7
8
Person #1
Name
*
First, Middle & Last
Gender
*
Please Select »
Male
Female
Date of Birth
*
MM slash DD slash YYYY
SSN - Last Four Digits
*
Race
*
Please Select »
A- Asian
B - Black or African American
I - American Indian or Alaska Native
P - Native Hawaiian or other Pacific Islander
W - White or Caucasian
M - Multiracial
O - Other
Military Status
*
Please Select »
A - Active
V - Veteran
N - No Affiliation
Health Insurance
*
Please Select »
A - Medicaid
B - Medicare
D - Direct Purchase
E - Employer Based
M - Military
S - State
O - Other
N - None
Hispanic?
*
Please Select »
Yes
No
Disabled?
*
Please Select »
Yes
No
School Years Completed
*
Please Select »
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17+
Person #2
Name
First, Middle & Last
Gender
Please Select »
Male
Female
Date of Birth
MM slash DD slash YYYY
SSN - Last Four Digits
Race
Please Select »
A- Asian
B - Black or African American
I - American Indian or Alaska Native
P - Native Hawaiian or other Pacific Islander
W - White or Caucasian
M - Multiracial
O - Other
Military Status
Please Select »
A - Active
V - Veteran
N - No Affiliation
Health Insurance
Please Select »
A - Medicaid
B - Medicare
D - Direct Purchase
E - Employer Based
M - Military
S - State
O - Other
N - None
Hispanic?
Please Select »
Yes
No
Disabled?
Please Select »
Yes
No
School Years Completed
Please Select »
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17+
Person #3
Name
First, Middle & Last
Gender
Please Select »
Male
Female
Date of Birth
MM slash DD slash YYYY
SSN - Last Four Digits
Race
Please Select »
A- Asian
B - Black or African American
I - American Indian or Alaska Native
P - Native Hawaiian or other Pacific Islander
W - White or Caucasian
M - Multiracial
O - Other
Military Status
Please Select »
A - Active
V - Veteran
N - No Affiliation
Health Insurance
Please Select »
A - Medicaid
B - Medicare
D - Direct Purchase
E - Employer Based
M - Military
S - State
O - Other
N - None
Hispanic?
Please Select »
Yes
No
Disabled?
Please Select »
Yes
No
School Years Completed
Please Select »
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17+
Person #4
Name
First, Middle & Last
Gender
Please Select »
Male
Female
Date of Birth
MM slash DD slash YYYY
SSN - Last Four Digits
Race
Please Select »
A- Asian
B - Black or African American
I - American Indian or Alaska Native
P - Native Hawaiian or other Pacific Islander
W - White or Caucasian
M - Multiracial
O - Other
Military Status
Please Select »
A - Active
V - Veteran
N - No Affiliation
Health Insurance
Please Select »
A - Medicaid
B - Medicare
D - Direct Purchase
E - Employer Based
M - Military
S - State
O - Other
N - None
Hispanic?
Please Select »
Yes
No
Disabled?
Please Select »
Yes
No
School Years Completed
Please Select »
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17+
Person #5
Name
First, Middle & Last
Gender
Please Select »
Male
Female
Date of Birth
MM slash DD slash YYYY
SSN - Last Four Digits
Race
Please Select »
A- Asian
B - Black or African American
I - American Indian or Alaska Native
P - Native Hawaiian or other Pacific Islander
W - White or Caucasian
M - Multiracial
O - Other
Military Status
Please Select »
A - Active
V - Veteran
N - No Affiliation
Health Insurance
Please Select »
A - Medicaid
B - Medicare
D - Direct Purchase
E - Employer Based
M - Military
S - State
O - Other
N - None
Hispanic?
Please Select »
Yes
No
Disabled?
Please Select »
Yes
No
School Years Completed
Please Select »
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17+
Person #6
Name
First, Middle & Last
Gender
Please Select »
Male
Female
Date of Birth
MM slash DD slash YYYY
SSN - Last Four Digits
Race
Please Select »
A- Asian
B - Black or African American
I - American Indian or Alaska Native
P - Native Hawaiian or other Pacific Islander
W - White or Caucasian
M - Multiracial
O - Other
Military Status
Please Select »
A - Active
V - Veteran
N - No Affiliation
Health Insurance
Please Select »
A - Medicaid
B - Medicare
D - Direct Purchase
E - Employer Based
M - Military
S - State
O - Other
N - None
Hispanic?
Please Select »
Yes
No
Disabled?
Please Select »
Yes
No
School Years Completed
Please Select »
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17+
Person #7
Name
First, Middle & Last
Gender
Please Select »
Male
Female
Date of Birth
MM slash DD slash YYYY
SSN - Last Four Digits
Race
Please Select »
A- Asian
B - Black or African American
I - American Indian or Alaska Native
P - Native Hawaiian or other Pacific Islander
W - White or Caucasian
M - Multiracial
O - Other
Military Status
Please Select »
A - Active
V - Veteran
N - No Affiliation
Health Insurance
Please Select »
A - Medicaid
B - Medicare
D - Direct Purchase
E - Employer Based
M - Military
S - State
O - Other
N - None
Hispanic?
Please Select »
Yes
No
Disabled?
Please Select »
Yes
No
School Years Completed
Please Select »
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17+
Person #8
Name
First, Middle & Last
Gender
Please Select »
Male
Female
Date of Birth
MM slash DD slash YYYY
SSN - Last Four Digits
Race
Please Select »
A- Asian
B - Black or African American
I - American Indian or Alaska Native
P - Native Hawaiian or other Pacific Islander
W - White or Caucasian
M - Multiracial
O - Other
Military Status
Please Select »
A - Active
V - Veteran
N - No Affiliation
Health Insurance
Please Select »
A - Medicaid
B - Medicare
D - Direct Purchase
E - Employer Based
M - Military
S - State
O - Other
N - None
Hispanic?
Please Select »
Yes
No
Disabled?
Please Select »
Yes
No
School Years Completed
Please Select »
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17+
Sources of Assistance
Housing Choice Voucher (Section 8)
Public Housing
HUD VASH Voucher
Permanent Supportive Housing
SNAP (Food Stamps)
Child Care Voucher
Affordable Care Act Subsidy
Emergency Furnace Repair
Emergency Furnace Replacement
LIHEAP
WIC
None
Other
Please indicate all sources of assistance receive by the household (please check all that apply):
Other Source of Assistance
Is anybody in the household currently between the ages of 14-24, and neither working nor attending school?
*
Please select »
Yes
No
Name of Person
*
Is anybody in the household currently affiliated with this agency as an employee/staff member, board member, or subcontractor, or related to any such member?
*
Please select »
Yes
No
Name of Person
*
Your Signature
*
Today's Date
*
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.
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