Intake Form - Reclaiming Our Greatness

Name(Required)

First Last

Year of Birth

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

What is your reason for contacting ROG?(Required)

Homeless

Move-In Cost Assistance

Rental Assistance (14-Day Notice Served)

Rental Assistance (Behind but no notice served)

Utility Assistance

Domestic Violence

Family Law Assistance (Divorce, child custody)

Other

Describe your reason for contacting ROG

Reason you need rental assistance

Amount Needed

How much can you contribute to this balance

How did you hear about ROG?

How many children live in your home?(Required)

Include anyone under the age of 24

What are their ages?

Employment

Are you currently employed?(Required)

Yes

If yes, are you working full-time or part-time?

Name of Employer(s)

How many hours per week

Hourly Pay

What other agencies have you contacted?(Required)

lease list any agencies you have contacted about this need. If none, please input “none” in text field

Are you disabled?(Required)

Yes

Do you have your own transportation(Required)

Yes

Do you need additional assistance?

Food

Clothing

Diapers, Wipes, Baby Supplies

Transportation

Hygiene Products

Other

Monthly Income and Assistance

Wages(Required)

Unemployment(Required)

SSI/SSDI(Required)

Veterans Benefits(Required)

TANF(Required)

SNAP/Food Benefits(Required)

Total Income and Assistance

Healthcare Coverage(Required)

Medicaid

Medicare

WIC(Required)

Yes

Share With Us(Required)

Please give us detailed information regarding your request for assistance. Please include specific amounts that you are requesting, move in or deadline dates and important information that is related this request. Space is limited so please give us the most important details. Do not leave this section blank.