Providing this information is optional; if you prefer not to answer write "prefer not to answer." If you or someone in your household is pregnant, you can include how many weeks pregnant in this section. This information (and your decision about whether to provide it) will not be used to determine eligibility for services.
Include all cash sources like wages, unemployment insurance, cash assistance, SSI/SSDI, child support, alimony, etc. but do not include food support, WIC, fuel assistance, or other non-cash benefits.
Referring Agency Information
Please provide the following information about the referring agency and contact person.
Please note that unfortunately our funding cannot typically cover hotel stays.
Some examples: family was denied EA for X reason; family's financial need is greater than our cap of $X and we are looking for supplemental funding sources; the family did not meet our program criteria for X reason; our agency does not typically offer this particular type of assistance