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Savannah Cares Intake Form

1Applicant Information

2Current Needs

3Budget Forms

4Documents

Head of Household
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Preferred method of communication*
- Select All
- Phone
- Text
- Email
Gender*
- Female
- Male
- Other
- Non-conforming
Ethnicity*
- African American/Black
- Asian
- Caucasian
- Hawaiian or Pacific Islander
- Hispanic
- Multi-racial
- Native American
- Other
Employer*
Monthly Household Income*

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Requested assistance*
- Select All
- Mortgage
- Rent
- Utility
Number of household members*
Other than yourself.
Number of children in household*
First Name
Last Name
Date of Birth
MM slash DD slash YYYY
Gender
- Female
- Male
- Other
- Non-conforming
Ethnicity
- African American/Black
- Asian
- Caucasian
- Hawaiian or Pacific Islander
- Hispanic
- Multi-racial
- Native American
- Other
First Name
Last Name
Date of Birth
MM slash DD slash YYYY
Gender
- Female
- Male
- Other
- Non-conforming
Ethnicity
- African American/Black
- Asian
- Caucasian
- Hawaiian or Pacific Islander
- Hispanic
- Multi-racial
- Native American
- Other
First Name
Last Name
Date of Birth
MM slash DD slash YYYY
Gender
- Female
- Male
- Other
- Non-conforming
Ethnicity
- African American/Black
- Asian
- Caucasian
- Hawaiian or Pacific Islander
- Hispanic
- Multi-racial
- Native American
- Other
First Name
Last Name
Date of Birth
MM slash DD slash YYYY
Gender
- Female
- Male
- Other
- Non-conforming
Ethnicity
- African American/Black
- Asian
- Caucasian
- Hawaiian or Pacific Islander
- Hispanic
- Multi-racial
- Native American
- Other
First Name
Last Name
Date of Birth
MM slash DD slash YYYY
Gender
- Female
- Male
- Other
- Non-conforming
Ethnicity
- African American/Black
- Asian
- Caucasian
- Hawaiian or Pacific Islander
- Hispanic
- Multi-racial
- Native American
- Other
First Name
Last Name
Date of Birth
MM slash DD slash YYYY
Gender
- Female
- Male
- Other
- Non-conforming
Ethnicity
- African American/Black
- Asian
- Caucasian
- Hawaiian or Pacific Islander
- Hispanic
- Multi-racial
- Native American
- Other
First Name
Last Name
Date of Birth
MM slash DD slash YYYY
Gender
- Female
- Male
- Other
- Non-conforming
Ethnicity
- African American/Black
- Asian
- Caucasian
- Hawaiian or Pacific Islander
- Hispanic
- Multi-racial
- Native American
- Other
First Name
Last Name
Date of Birth
MM slash DD slash YYYY
Gender
- Female
- Male
- Other
- Non-conforming
Ethnicity
- African American/Black
- Asian
- Caucasian
- Hawaiian or Pacific Islander
- Hispanic
- Multi-racial
- Native American
- Other

Save and Continue Later

Monthly Household Income
Enter 0 if the income or expenses don't apply to you.
Wages*
SSI*
SSDI*
SSA*
VA Benefits*
Child Support*
TANF*
Alimony*
Retirement*
Utility Checks*
Other Cash Support*
Monthly Household Expenses
Housing (Rent/Mortgage)*
Cell Phone*
Internet/Cable*
Auto Payment(s)*
Auto Repairs/Maintenance/Gas*
Medications*
Doctor Co-Pays*
Water Bill*
Electricity/Gas Bill*
Food (Groceries)*
Insurances (Auto/Renter)*
Loans*
Credit Cards*
Other*

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State Identification*
Head of Household (upload size limit: 5MB)
Accepted file types: jpg, pdf, png, gif, Max. file size: 5 MB.
Social Security Card*
Head of Household (upload size limit: 5MB)
Accepted file types: jpg, pdf, png, gif, Max. file size: 5 MB.
Mortgage verification or Lease/Rental agreement*
Please provide the first page and the signature page of the lease. (upload size limit: 5MB)
Accepted file types: jpg, pdf, png, gif, Max. file size: 5 MB.
Separation Notice/Proof of loss of income*
Paycheck stubs, letter from employer stating decrease in hours. Must be able to provide documentation at least 30 days of loss of income. (upload size limit: 5MB)
Accepted file types: jpg, pdf, png, gif, Max. file size: 5 MB.
Dispossessory Warrant/Notice to Vacate*
Letter from leasing agent or property owner stating amount due and months outstanding. Please provide total amount due. (upload size limit: 5MB)
Accepted file types: jpg, pdf, png, gif, Max. file size: 5 MB.
Outstanding utility bills*
Electricity, water and/or gas bill ONLY. (upload size limit: 5MB)
Drop files here or

Accepted file types: jpg, pdf, png, gif, Max. file size: 5 MB, Max. files: 3.
Verification of current household earned income*
Unemployment benefits, returned to work, new employment, SSI and SSDI, child support and alimony where applicable
- Returned to work/new employment
- SSI/SSDI or SSA
- VA Benefits
- Child Support
- Alimony
- Unemployment Benefits
- None
Returned to work/new employment verification*
(upload size limit: 5MB)
Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB.
SSI/SSDI or SSA verification*
(upload size limit: 5MB)
Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB.
VA Benefits verification*
(upload size limit: 5MB)
Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB.
Child Support verification*
(upload size limit: 5MB)
Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB.
Alimony verification*
(upload size limit: 5MB)
Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB.
Unemployment Benefits verification*
(upload size limit: 5MB)
Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB.
I understand that:
Rental, mortgage and/or utility assistance is not guaranteed even when a person appears to be eligible during the first client screening.*
- Yes
All information will need to be verified with appropriate documentation before any financial assistance is given.*
- Yes
The information that the applicant is provides is truthful, complete and accurate.*
- Yes
I give consent to having this website store my submitted information. I understand that my application will not be submitted if all pertinent information is not submitted.*
- Yes
I understand that I have 48 hours from the date of application submission to present all requested information or my application will be placed on the waiting list for review and may cause additional delay in processing.*
- Yes
Signature*
Name
This field is for validation purposes and should be left unchanged.

Save and Continue Later

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