Financial Assistance Screening Financial Assistance Screening Consent(Required)By consenting I agree to have the information provided below entered into United Way of Suwannee Valley's homeless information system to further assess for available assistance and referral to agencies in the area for assistance. I agree to the privacy policy.Name(Required) First Last Date of Birth(Required) Month Day Year Social SecurityPlease enter without any spaces or dashes.Race American Indian, Alaska Native, or Indigenous Asian or Asian America Black, African American, or African Hispanic/Latina/e/o Middle Eastern or North African Native Hawaiian or Pacific Islander White HiddenEthincity (DO NOT USE) Non-Hispanic/Non-Latin(a)(o)(x) Hispanic/Non-Latin(a)(o)(x) GenderPlease select all that apply Woman Man Culturally Specific Identity (e.g., Two-Spirit) Transgender Non-Binary Questioning Different Identity Different IdentityCould you please provide us with more detail about your gender identity. Would you require or feel more comfortable with a translation service when speaking with us? Yes No What is your preferred language? VeteranAre you or a family member (those currently living with you) a veteran? Yes No ConsentIf you are a veteran would you allow us to forward your Name, Date of Birth, and contact information to local veterans' services to contact you? I agree to the privacy policy.PhoneEmailIf you do not regularly check your email, it may be best to not provide us with one. Do you live in one of the following? Brandywine Apartments Cedar Park Apartments Columbia County Housing Authority Jasper Apartments Lafayette Apartments Lake City Villas Lakewood Apartments Suwannee County Housing Authority Suwannee Pointe Apartments The Meadows Apartments Village Oaks Apartments Windsong Apartments Section 8 N/A Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code HiddenHave you been affected by hurricane Idalia? Yes No Have you been affected by hurricane Debby? Yes No Have you been affected by hurricane Helene? Yes No How have you been affected by the hurricane(s)? Are you currently living in FEMA temporary housing?Shelter/Mobile Home/Trailer Yes No What is your FEMA Number? Do you have an ongoing case with the Department of Children and Families for reunification? Yes No Please give us a brief description of your situation:Household Type(Required)Please pick the household that best describes your family. Single adult Household with more than one adult Household with adults and children Individual between the ages of 18 and 24 Inidividual between the ages of 18 and 24 and has children Living Situation(Required)Please pick the situation that best describes your living/sleeping arrangements. Own your home/Mortgage Renting Living with family Living with friends Living in a hotel Homeless shelter or domestic violence shelter Outdoors, in a vehicle, or in the woods Jail/Prison Residential Facility (ex a nursing home) Substance use treatment facility Hospital If living in a rental, are you being evicted or have you received a 3 or 10 day notice? If you are living with friends/family are they asking you to leave?(Required) Yes No How much is your rent per month?(Required)How many bedrooms does your rental have?(Required) Efficiency 1 Bedroom 2 Bedrooms 3 Bedrooms 4 Bedrooms What is the date of the eviction?(Required) Month Day Year HiddenDo you or someone in your household have a disability?This refers to a physical disability, mental health condition, substance use or history, developmental disability, or severe head injury. Yes No Do you or your children receive health insurance through one of the following? Sunshine Health Medicaid Ambetter Medicaid We Care Medicaid Do you or someone in your household have a disability? Physical Disability Mental Health Issue Substance use or History of Substance Use Developmental Disability Other mental impairment (such as severe head injury) Health(Required)Please choose the option that best describes your health or that of a family member In good health Has a temporary minor health issue (recent sickness such as cold or flu) Has an ongoing health issue that is well managed (currently receiving care, taking prescribed medication regularly) Has an untreated health issue, but not experiencing any pain/symptoms currently (Prescribed medication you should be taking, but do not have access to currently) Disabled, applying for disability; ongoing treatment for major illness (dialysis/cancer) Disabled experiencing minor-moderate pain/sypmtoms 2 more more disabilities (physical, mental, developmental, head trauma) Several compounding health issues (mental health, substance use, physical health) that make it difficult to live/function on your own In mental health or physical health emergency. Should be hospitalized or in emergency room. Length of stay in your current living situation(Required) 1 night or less 2 to 6 nights More than 1 week but less than 1 month More than 1 month but less than 3 months More than 3 months but less than 1 year 1 year or longer When did you become homeless? Month Day Year Number of times homeless in the last 3 years 1 2 3 4 or more Length of time homeless Less than 1 Month 1-2 Months 3-4 Months 5-6 Months 7-8 Months 9-10 Months 10-12 Months More than 1 Year but less than 2 Years. More than 2 Years Please select addtional concerns that may affect your ability to obtain or stay in housing: No household income Prior evictions English as a second language Bad credit or excessive debt Criminal record or history of incarceration History with housing discrimination based on race or ethnicity Elderly, 60+ years old Recent medical emergency causing financial hardship Other recent financial hardship (e.g. emergency car repair) History of substance use Are you or a household member pregnant? Are there children under the age of 5 in the home? Are you a domestic violence victim or survivor? Yes No When was the last incident? Within the last 3 months 3 to 6 months ago 6 to 12 months ago More than 1 year ago Are you currently fleeing? Yes No Additional Household MembersName First Last Date of birth Month Day Year Social Security NumberRace American Indian, Alaska Native, or Indigenous Asian or Asian America Black, African American, or African Hispanic/Latina/e/o Middle Eastern or North African Native Hawaiian or Pacific Islander White HiddenEthincity Non-Hispanic/Non-Latin(a)(o)(x) Hispanic/Non-Latin(a)(o)(x) GenderPlease select all that apply Woman (Girl, if child) Man (Boy, if child) Culturally Specific Identity (e.g., Two-Spirit) Transgender Non-Binary Questioning Different Identity Relationship to head of household Spouse/Partner/Boyfriend/Girlfriend Child Other relation to head of household Non-relation to head of household Do you have additional household members? Yes No 2Name First Last Date of birth Month Day Year Social Security NumberRace American Indian, Alaska Native, or Indigenous Asian or Asian America Black, African American, or African Hispanic/Latina/e/o Middle Eastern or North African Native Hawaiian or Pacific Islander White HiddenEthincity Non-Hispanic/Non-Latin(a)(o)(x) Hispanic/Non-Latin(a)(o)(x) GenderPlease select all that apply Woman (Girl, if child) Man (Boy, if child) Culturally Specific Identity (e.g., Two-Spirit) Transgender Non-Binary Questioning Different Identity Relationship to head of household Spouse/Partner/Boyfriend/Girlfriend Child Other relation to head of household Non-relation to head of household Do you have additional household members? Yes No 3Name First Last Date of birth Month Day Year Social Security NumberRace American Indian, Alaska Native, or Indigenous Asian or Asian America Black, African American, or African Hispanic/Latina/e/o Middle Eastern or North African Native Hawaiian or Pacific Islander White HiddenEthincity Non-Hispanic/Non-Latin(a)(o)(x) Hispanic/Non-Latin(a)(o)(x) GenderPlease select all that apply Woman (Girl, if child) Man (Boy, if child) Culturally Specific Identity (e.g., Two-Spirit) Transgender Non-Binary Questioning Different Identity Relationship to head of household Spouse/Partner/Boyfriend/Girlfriend Child Other relation to head of household Non-relation to head of household Do you have additional household members? Yes No 4Name First Last Date of birth Month Day Year Social Security NumberRace American Indian, Alaska Native, or Indigenous Asian or Asian America Black, African American, or African Hispanic/Latina/e/o Middle Eastern or North African Native Hawaiian or Pacific Islander White HiddenEthincity Non-Hispanic/Non-Latin(a)(o)(x) Hispanic/Non-Latin(a)(o)(x) GenderPlease select all that apply Woman (Girl, if child) Man (Boy, if child) Culturally Specific Identity (e.g., Two-Spirit) Transgender Non-Binary Questioning Different Identity Relationship to head of household Spouse/Partner/Boyfriend/Girlfriend Child Other relation to head of household Non-relation to head of household Do you have additional household members? Yes No 5Name First Last Date of birth Month Day Year Social Security NumberRace American Indian, Alaska Native, or Indigenous Asian or Asian America Black, African American, or African Hispanic/Latina/e/o Middle Eastern or North African Native Hawaiian or Pacific Islander White HiddenEthincity Non-Hispanic/Non-Latin(a)(o)(x) Hispanic/Non-Latin(a)(o)(x) GenderPlease select all that apply Woman (Girl, if child) Man (Boy, if child) Culturally Specific Identity (e.g., Two-Spirit) Transgender Non-Binary Questioning Different Identity Relationship to head of household Spouse/Partner/Boyfriend/Girlfriend Child Other relation to head of household Non-relation to head of household Do you have additional household members? Yes No 6Name First Last Date of birth Month Day Year Social Security NumberRace American Indian, Alaska Native, or Indigenous Asian or Asian America Black, African American, or African Hispanic/Latina/e/o Middle Eastern or North African Native Hawaiian or Pacific Islander White HiddenEthincity Non-Hispanic/Non-Latin(a)(o)(x) Hispanic/Non-Latin(a)(o)(x) GenderPlease select all that apply Woman (Girl, if child) Man (Boy, if child) Culturally Specific Identity (e.g., Two-Spirit) Transgender Non-Binary Questioning Different Identity Relationship to head of household Spouse/Partner/Boyfriend/Girlfriend Child Other relation to head of household Non-relation to head of household Do you have additional household members? Yes No 7Name First Last Date of birth Month Day Year Social Security NumberRace American Indian, Alaska Native, or Indigenous Asian or Asian America Black, African American, or African Hispanic/Latina/e/o Middle Eastern or North African Native Hawaiian or Pacific Islander White HiddenEthincity Non-Hispanic/Non-Latin(a)(o)(x) Hispanic/Non-Latin(a)(o)(x) GenderPlease select all that apply Woman (Girl, if child) Man (Boy, if child) Culturally Specific Identity (e.g., Two-Spirit) Transgender Non-Binary Questioning Different Identity Relationship to head of household Spouse/Partner/Boyfriend/Girlfriend Child Other relation to head of household Non-relation to head of household DocumentsIf able to, please upload digital copies or photos of I.D.s for those in the household, eviction notice, 3 Day or 10 Day notice, or note from head of household that you may no longer stay with them. Drop files here or Select files Accepted file types: jpg, png, pdf, Max. file size: 128 MB.
