Universal Assistance Intake Form
1. Select All Assistance Needed
Food Assistance
Housing Assistance
Phone Service
Medical/Health Assistance
Employment Assistance
Education Or Training
Clothing Assistance
Drug or Alcohol Assistance
Utility Assistance
Domestic Issues
Internet Service
No elements found. Consider changing the search query.
List is empty.
2. Select All Qualifying Benefits You Have
Medicaid
Foodstamps
WIC
SSI (Supplemental Income)
SSDI (disability) run under INCOME.
SSA or (Retirement) run under INCOME
Housing (HUD, Section8, Voucher)
Income: W2 or Tax Return
Veteran's Survivor Benefits
Medicare(Red, White & Blue Card) Not for Lifeline
Free Or Reduced School Lunch Program
Pell Grant
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List is empty.
3a. First Name
3b. Last Name
4. Date of birth: (Tip: Tap on the year 1st)
*
5. Social Security Number
Address
Street Address
City
State
Postal code
Name of Apartment, Facility, or Shelter
7. Contact Number To Reach You:
8. Email:
9. Where did you hear about us?
Document Page
State ID or Driver's License
State ID
Award Letter (Foodstamps, Medicaid, SSI, Disability, Social Security(Retirement), Utility Bill
Award Letter or Utility Bill
Birth Certificate
Birth Certificate
Social Security Card
Social Security Card
Do you have Medicare?
Yes
No
17. Do you have Medicare?
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