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Family Life
Covering Kids and Families of Indiana (CKF)
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
Income Tax Information
News
About
Annual Reports, Audit Results, and 990 Forms
Board of Directors
Customer Satisfaction Survey and Community Needs Assessment
Employment Opportunities
Joan E. Cline Memorial Scholarship
Make a Donation
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Members Area
Home
Services
Family Life
Covering Kids and Families of Indiana (CKF)
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
Income Tax Information
News
About
Annual Reports, Audit Results, and 990 Forms
Board of Directors
Customer Satisfaction Survey and Community Needs Assessment
Employment Opportunities
Joan E. Cline Memorial Scholarship
Make a Donation
FAQs
Locations
Contact
Members Area
Menu
Home
Services
Family Life
Covering Kids and Families of Indiana (CKF)
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
Income Tax Information
News
About
Annual Reports, Audit Results, and 990 Forms
Board of Directors
Customer Satisfaction Survey and Community Needs Assessment
Employment Opportunities
Joan E. Cline Memorial Scholarship
Make a Donation
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Indicate needed assistance (check all that apply):
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Mortgage Payment
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Childcare Payments
Mental Health Copay
Food Assistance
Other Emergency
Other Emergency Information
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Home Ownership Type
*
Own
Rent
Other
Other Ownership Type
*
Renters: Do you receive subsidized housing vouchers?
*
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Did you have earned income prior to the stay-at-home order?
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Total Annual Income
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Please indicate your total annual income from all income sources.
Do you qualify for unemployment insurance?
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Household Members
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Hispanic?
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Disabled?
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School Years Completed
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Person #2
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Person #3
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M - Multiracial
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School Years Completed
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1
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10
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15
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Person #4
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Date of Birth
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I - American Indian or Alaska Native
P - Native Hawaiian or other Pacific Islander
W - White or Caucasian
M - Multiracial
O - Other
Military Status
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N - No Affiliation
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M - Military
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N - None
Hispanic?
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Disabled?
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School Years Completed
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1
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3
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8
9
10
11
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15
16
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Person #5
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Race
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P - Native Hawaiian or other Pacific Islander
W - White or Caucasian
M - Multiracial
O - Other
Military Status
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A - Active
V - Veteran
N - No Affiliation
Health Insurance
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A - Medicaid
B - Medicare
D - Direct Purchase
E - Employer Based
M - Military
S - State
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N - None
Hispanic?
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Disabled?
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Yes
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School Years Completed
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0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
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Person #6
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Gender
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Male
Female
Date of Birth
MM slash DD slash YYYY
SSN - Last Four Digits
Race
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W - White or Caucasian
M - Multiracial
O - Other
Military Status
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V - Veteran
N - No Affiliation
Health Insurance
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Hispanic?
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Disabled?
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School Years Completed
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0
1
2
3
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10
11
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Person #7
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Male
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Date of Birth
MM slash DD slash YYYY
SSN - Last Four Digits
Race
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P - Native Hawaiian or other Pacific Islander
W - White or Caucasian
M - Multiracial
O - Other
Military Status
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A - Active
V - Veteran
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Health Insurance
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E - Employer Based
M - Military
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N - None
Hispanic?
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Disabled?
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Yes
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School Years Completed
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0
1
2
3
4
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7
8
9
10
11
12
13
14
15
16
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Person #8
Name
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Gender
Please Select »
Male
Female
Date of Birth
MM slash DD slash YYYY
SSN - Last Four Digits
Race
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I - American Indian or Alaska Native
P - Native Hawaiian or other Pacific Islander
W - White or Caucasian
M - Multiracial
O - Other
Military Status
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V - Veteran
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Health Insurance
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B - Medicare
D - Direct Purchase
E - Employer Based
M - Military
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N - None
Hispanic?
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Disabled?
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Yes
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School Years Completed
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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?
*
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No
Name of Person
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Your Signature
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Today's Date
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