Name
*
First Name
Last Name
Email
*
Phone
(###)
###
####
Current Mailing Address
*
Physical Address
*
How long have you been at your current address?
*
If you have lived at your current address for less than one year, where did you live before?
Date of Birth
*
MM
DD
YYYY
Sex
*
Male
Female
Are you a current resident of White County, Georgia?
*
Yes
No
If yes, how long have you lived in White County?
Have you been assisted by White County Caring & Sharing in the last six months
*
Yes
No
Marital Status
*
Single
Married
Separated
Divorced
Widowed
Are you employed?
*
Yes
No
If yes, where are you employed?
If unemployed, when and where did you last work?
If unemployed, why did you leave your last job?
I am currently employed
Quit
Laid Off
Terminated
Other
If unemployed, how long were you in your last job?
If unemployed, are you currently seeking employment?
I am currently employed
Yes
No
If currently seeking employment, list all the dates and places you have applied:
Spouse/Partner's Name
First Name
Last Name
Is your spouse/partner employed?
I don't have a spouse/partner
Yes
No
If your spouse/partner is not employed, why not?
Number of people living in your household (including you)
*
Total number of adults (over 18) living in your household (including you)
*
Total number of children (18 and under) living in your household
*
List the names and date of birth of all dependents in your household, along with your relationship to them
(Example: Billy Sue Jones, 10/01/2002, daughter)
How did you get in your current financial situation?
*
If we assist you at this time, what are your plans so that you don’t continue to need assistance?
*
What is your most pressing need at this time? (Which one bill do you need help with the most?)
*
In the event WCCS must communicate with you by telephone to give/receive information, efforts are made to preserve confidentially. Please choose who we may speak with by phone. This also applies to when you call back to see if your application has been approved.
Speak only with me (Person’s Name on Application) at the number on application.
Speak with anyone in my household.
Income from Employment (monthly)
Income from Unemployment (monthly)
Income from Social Security (monthly)
Income from WIC (monthly)
Income from Disability (monthly)
Income from Child Support (monthly)
Income from Any Other Source (monthly)
How much cash do you have at this time?
TOTAL INCOME
Cable TV/Satellite Dish Monthly Expense
Car Payment Monthly Expense
Cigarettes/Tobacco Monthly Expense
Clothing Monthly Expense
Credit Card Payments Monthly Expense
Doctor/Dentist Monthly Expense
Eating Out Monthly Expense
Electricity/Propane Monthly Expense
Food/Groceries Monthly Expense
Gasoline/Oil for Car Monthly Expense
Hairdresser/Nail Salon Monthly Expense
Household/Toiletries Monthly Expense
Insurance Monthly Expense
Loans Monthly Expense
Prescriptions Monthly Expense
Rent/Mortgage Monthly Expense
Telephone/Cell Phone/Internet Monthly Expense
Water/Sewer Monthly Expense
Other Monthly Expense
TOTAL EXPENSES
IF YOU NEED ASSISTANCE WITH RENT, Enter Landlord's Name
IF YOU NEED ASSISTANCE WITH RENT, Enter Landlord's Phone Number
IF YOU NEED ASSISTANCE WITH POWER, please choose your electricity provider
Georgia Power
HEMC
IF YOU NEED ASSISTANCE WITH POWER, please enter your ACCOUNT NUMBER
IF YOU NEED ASSISTANCE WITH POWER, please indicate whether your account is prepaid
My account is prepaid
My account is NOT prepaid
IF YOU NEED ASSISTANCE WITH PROPANE, what is the name and address of your propane provider?
IF YOU NEED ASSISTANCE WITH PROPANE, what is your account number with your propane company?
Please enter your full legal name. By entering your name, you affirm that you are signing this document and that all information on this application is true and correct.
*
Today's Date
MM
DD
YYYY
