SOS IntakeForm by HUNwIU


									Family Name                                                       Date of Birth

Social Security number

This is to pay                                                    Amount Requested

                 Payment plan:
                         Total amount owed to landlord

                         Amount client will pay Up Front to landlord

                         Amount to be paid in monthly payments

                         Amount requested to Season of Sharing

                         Landlord Waive

                         Other Resources:                         FEPCO






                                                                  SF HOME Project



                         Budget Sheet
                         Copy of client portion of payment/payment plan agreement
                         Copy of applicant's identification card/Social Security Card
                         Copy of children's birth certificates
                         Copy of income verification
                         Copy of lease or rental agreement/HAP
                         Letter from Physican describing need
                         Current statement of rent due from landlord (3day notice)
                         W-9 form/Proof of Ownership

Landlord name                                       Telephone                           Tax Id #

Address                                                                                     SS#

City                                                      State                               Zip
                                                                         Critical Family Needs/ Housing Assistance
                                                                                                    Intake Form
                                                 This section to be completed by Agency Representative

County:        Alameda                 Contra costa       Marin             Napa             SF               S.M.         S.C.     Solano         Sonoma

Program:        CFN           HA             Has Applicant used program before?               Yes          When?                                          No

Date of Initial contact                                             If yes, when and what occurred
 Name                                                                       D.O.B.                                         SS#

Address                                                                     City                                           Zip                  Tel#

New Address                                                                 City                                           Zip                  Tel#

# Children under 18                  Dates of birth                                                                  Total in Household

      Single Parent        Intact Family        Elderly                 Disable           Minor                    Other

Family Ethnicity (optional)

If Applicant has live in the county for less than 2 years, date move to the county

Former address / County

Monthly Net Income                                                  Anticipated changes

Income Source:                Work      CalWORKs          SSI          SS          UIB            UIB        FC             Other

Referral Agency                                                                                   Contact Person
Address                                                                                                     Tel #

Request:       1St/Last Month rent             Deposit                 Delinquent Rent/ Mortgage             Other

Reason:         Disability/Illness              Unemploment                   Family Separation               Public Assistance                        Other

Explanation (attach additional sheets if necessary):

What other actions have been taken to alleviate this need?

If Approved, make check payable to (Landlord/Vendor):                                                                             Amount

Address                                                      City                                    Zip                                 Tel#

If Approved, make check # 2 payable to (Landlord/Vendor):                                                                         Amount

Address                                                    City                                      Zip                                 Tel#

For (Client's Name):

                                                                To be completed by applicant

I hereby give permission to contact any agency/landlord who could be helpful in understanding my situation, and I give
consent to release information necessary to receive assistance from the San Francisco Chronicle Season of Sharing Fund.
This form was completed in its entirely by an authorized worker and approved by me prior to my signing.

Signature                                                                                    Date

Can a program representative contact you to see if this grant has helped resolve your situation?                           Yes                    No
Please initial heare:
                                                          Applicant not to write in this section

CFN:            Denial                   Approved                                     If Approved, Amount: $

HA:             Denial                   Approved                                     If Approved, Amount: $

Assistance was denied, reason:

Authorized Signature                                                                 Phone                                        Date
Label 6
                                                                  San Francisco Chronicle

                                                                Total #'s of Adults
Family name:                                                    Total #'s of Children
   Monthly Income                               Future Income   Total in the family
If future income is considered enter date                       Monthly Expenses

Applicant net Wages                                             Rent

Spouse net Wages                                                PG&E
Other net Wages                                                 Telephone

Child Support                                                   Water
AFDC/TANF                                                       Garbage
GA                                                              Insurance
SSA                                                             Child care
SSI/SDA/SDI                                                     Car payments
Food Stamps                                                     Installment Payments
Student Loans                                                   Food
Unemployment                                                    Transportation
Total                            $          -   $          -    Medical/Medicine

Monthly Income                   $          -   $          -    Cigarrettes
Monthly Expenses                 $          -   $          -    Cable TV
Monthly Balance $                           -   $          -    Toiletries/Personal
Available for Payment plan                                      Tui/Books
                                                                Other Taxesexpenses/Garni
  $                -                            $          -    Total                   $   -

Client Signature                                                Date
JCForms 11/05/03

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