Intake Application DateFirst NameLast NameDOBAgeSocial Security NumberAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail Preferred LanguageEducationNoneGEDHigh School DiplomaTwo-Year Vocational TrainingAssociates DegreeBachelors DegreeMasters DegreeOtherRaceAsianAmerican Indian/Alaskan NativeBlack/African-AmericanBlack/African-American & WhiteCaucasianNative Hawaiian/Other Pacific IslanderAmerican Indian/Alaskan Native & BlackOther Multi-RacialEthnicityHispanicNon-HispanicGenderMaleFemaleMarriage StatusSingleMarriedSeparatedDivorcedWidowedNumber in Household (Include self)Is the Head of Household Disabled (yes) No Female (yes) No Foreign Born (yes) No Veteran of US Armed Services (yes) No If a Veteran, where you honorably discharged (yes) No Do you have a DD214? (yes) No Are you homeless?If so, how long?Please explain homeless situationAre any members of the household disabled?HouseholdNumber of children in householdName First Last RelationshipSocial Security NumberDate of BirthName First Last RelationshipSocial Security NumberDate of BirthFinancial InformationPlease upload a valid ID Acceptable forms of ID: Driver's License ID Card Passport If you don't have any of the above, please stop here and call 919-834-0666.Max. file size: 50 MB. Please upload a valid ID Acceptable forms of ID: Driver's License ID Card Passport If you don't have any of the above, please stop here and call 919-834-0666. Household income $Total amount in bank accounts $Cash BenefitsWagesAlimonyChild SupportDisabilityDividends/InterestOvertimeRetirementSocial SecurityWork First/TANFOtherNon-Cash BenefitsFood Stamps (SNAP)Health Insurance*YesNoEmployment-BasedMedicaidOtherReceive Child Support Yes No Section 8 (HCV) Yes No Public Housing Yes No Permanent Supportive Housing Yes No HUD-VASH Yes No LIHEAP Yes No Child Care Voucher Yes No INCOME VERIFICATION Check Stub UI SSI Other File Drop files here or Select files Max. file size: 50 MB. Please upload income document Income Documents Include: Last 3 months of pay stubs Work First or Benefits Awards Letters Unemployment Breakdown If you don't have any of documents, stop here and call 919-834-0666 EmploymentPresent Employer Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Contact NumberEmployment Type Full Time Part Time Monthly IncomeNet IncomeAre you self-employed? Yes No Are you a farm/migrant worker? Yes No List previous/part-time employment:Business Name and AddressStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Business Name and AddressStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Business Name and AddressStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Authorization We are a participating agency of the North Carolina Homeless Management Information System (HMIS) to collect and report on information about the clients we serve. We collect personal information directly from you for reasons that are discussed in the HMIS Privacy Practices. We may be required to collect some personal information by law or by organizations that give us money to operate this program. Other personal information that we collect is important to run our programs, to improve services for emergency assistance, and to better understand the needs of persons needing assistance. We only collect information that we consider to be appropriate. Additional information may be required of Veteran Applicants I/We authorize Passage Home to: Pull my/our credit and criminal report and review my/our credit file for informational inquiry purposes; and Contact employers and Landlords/rental references to verify that information submitted is correct. Contact client at address, telephone numbers, and e-mails provided on the intake form. I/We understand that any intentional or negligent representation(s) of the information contained on this form may result in civil liability and/or criminal liability under the provisions of Title 18, United States Code, and Section 1001 and will automatically disqualify you from any of our housing and services. If all fields aren’t complete, you will not be able to sign. ApplicantDate MM slash DD slash YYYY Co-ApplicantDate MM slash DD slash YYYY [wp_e_signature_sad doc=”4″]
