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 Intake ROMA Scale Please fill out all sections and submit for signature. Basic Life Skills* NOT APPLICABLE My family has information, skills and access to others for help and support when needed and provides help and support for others (LS-10). My family generally prefers to handle problems for themselves but maintains interest and participation in activities outside the home (LS-8). My family knows when and how to ask for help outside the home and knows who to ask other than local agencies (LS-6). My family depends on various agencies' services for help and support outside the home (LS-3). My family has limited contact with others outside the home and has no one to call for help or support (LS-1). Childcare* NOT APPLICABLE Child Care is available and adequate without subsidy. (CC-8) Child Care is available and adequate with subsidy. (CC-5) Some Child Care is available but it is inadequate to meet my current needs. (CC-4) My income qualifies for a subsidy but I remain on a waitlist. (CC-3) No Child Care is available that meets my needs. (CC-1) Education* NOT APPLICABLE I have a Masters or Doctorate Degree (ED-10). I have a Bachelors Degree (ED-9). I have an Associates Degree (ED-8). I have a Vocational education or I have technical, business, or professional training (ED-7). I have been certified or have another credential (ED-6). I have a high school diploma or G.E.D. (ED-5). I have basic reading, writing, math skills but no high school diploma or G.E.D. (ED-4). English is not my first language and it is difficult for me to understand it and speak comfortably (ED-3). I did attend High School, but I'm lacking in the area of reading, writing, and basic math skills (ED-2). I did not attend high school and I have difficulty with reading, writing and basic math skills (ED-1). Health GW* NOT APPLICABLE My family is covered by private (or employer provided) health insurance. We take all needed medication as prescribed (HGW-10). My family has health insurance. We do not receive medical subsidies but sometimes must access other resources for medicine, co-pays, or other medical care which is not covered by my health insurance (HGW-8). My family receives medical assistance and/or is able to meet our medical needs most of the time (HGW-6). My family receives some medical assistance but some of my medical needs go unmet (HGW-4). My children/family have no health coverage because I cannot afford the premium (HGW-1). Income Management* NOT APPLICABLE My family pays our bills on time, puts money in savings and is on top of managing our debt each month (IM-10). My family manages our debt but we have been unable to put money into savings (IM-9). My family has begun to pay off our debt. We have some money for household spending (IM-8). My family has a poor credit record, but we have a budget for our expenses and a plan for savings (IM-7). My family can meet our basic living expenses (housing, utilities, food, clothing). We do not qualify for credit (IM-6). My family receives subsidized assistance (housing, utilities, food stamps, medicaid, Work First) and we pay most of our bills on time. We cannot get credit (IM-5). My family struggles to make car payments, cell phone payments, Cable TV, and household furnishings. We often cannot pay all our bills each month (IM-3) My family is unable to pay basic living expenses (housing, food, utilities, clothing) month-to-month (IM-1). Nutrition* NOT APPLICABLE My family is able to afford nutritious food of choice without food bank, food stamps or other subsidy assistance (N-10). My family is able to afford nutritious food most of the time without food bank, food stamps or other subsidy assistance even though our choices may be limited (N-8). My family receives Food Stamps and is able to afford nutritious food with the occasional help of a food bank and ongoing receipt of food stamps (N-6) My family is unable to afford food without the help of a food pantry, soup kitchen and the use of food stamps to meet our survival needs (N-3) My family is unable to afford food and often misses meals due to the absence of food and a food assistance subsidy (N-1) Parental Support* NOT APPLICABLE Father and Mother cooperate together to provide consistent, adequate financial and emotional support for child(ren) (PS-10). Father and Mother have consistent contact with child(ren) and provide adequate financial and emotional support most of the time (PS-8). Father and/or Mother have limited contact with child(ren) and provide limited financial and emotional support (PS-5). Father and/or Mother relies totally on the other (or another individual) to provide most of the financial and emotional support for the child(ren) (PS-3). Father and/or Mother is absent from the home, has no contact with the child(ren) and provides no financial support (PS-1). Transportation* NOT APPLICABLE I have a legal and valid Drivers License, Maintain a legal and reliable vehicle, and all my transportation needs are met. (TRNSP-10) I have access to public or private transportation for all my transportation needs. (TRNSP-8) I have access to public or private transportation for most of my transportation needs. (TRNSP-5) I have a legal and valid Drivers License and access to a vehicle or public transportation for some transportation needs. (TRNSP-4) I have access to public transportation for some transportation needs. (TRNSP-3) I have a Drivers License but no transportation is available. (TRNSP-2) I have no current Drivers License and no access to public or private transportation. (TRNSP-1) Staff Name* 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″]