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Jackson County Application For Assistance

Birthday
Please select the option that best describes your current living situation.
Renting a home pending eviction
Renting a home being condemned
Own a home being forclosed
Own a home being condemned
Staying with family or friends
Staying in a hotel
Staying in a camper or RV
Currently in a shelter
Staying in a car
Staying in a tent or campground
Unsheltered / living outside
Other (Explain in "Notes")
Do you have reliable transportation?
Yes
No
Are you, or anyone else in the household currently pregnant?
Yes
No
Prefer not to say
Are you or any household member on this application currently serving ACTIVE DUTY or are a MILITARY VETERAN?
Yes
No
Prefer not to say
Are you or any household member on this application currently experiencing or fleeing DOMESTIC VIOLENCE?
Yes
No
Prefer not to say
Number of ADULTS in Household
1
2
3
Number of CHILDREN in the Household
1
2
3
4
5
6
Please select ALL sources of income for your household.
Please select ALL types of debt that you currently owe that we may be able to assist with.
Do you or anyone in your household have physical or mental HEALTH CHALLENGES that we can help accommodate?
Yes
No
Prefer not to say
Do you or anyone in your household have past EVICTIONS on record?
Yes
No
Prefer not to say
Do you or anyone in your household have CRIMINAL CHARGES pending or on record?
Yes
No
Prefer not to say
Please select any other of the following choices that you would like additional support from your case manager to help you.
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