CAApplicationForm

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I understand that the mission of Dorcas Ministries is to support families and individuals in crisis. This emergency assistance is not intended to be an income supplement or to be provided on a regular basis. By accepting the terms of this form, I give Dorcas Ministries permission to contact whomever necessary to verify my need, make a responsible decision regarding assistance to my household, and to seek further resources with regard to my request. This permission includes but is not limited to, landlords, mortgage companies, utility or other service providers, medical providers and pharmacies.

I also understand the information I provide will be used to verify my need, negotiate on my behalf, and to assist my household or other agencies assisting my household. My acceptance of this form indicates that all information I have given Dorcas Ministries is accurate and complete to the best of my knowledge.

I understand that if I have given false information my household and I will be barred from receiving any future assistance from Dorcas Ministries. Also, the incident may be shared with other organizations.

 


Childcare Assistance


Applicant Information

Parent (s) Name:

Mother: 

Father: 

Date : 

New Renewal

Phone:

Cell Phone:

Current address:

Email:

City:

State:

ZIP Code:

Own Rent

How long?

Employment Information

Current employer:

Employer Address:

How long?

Supervisor:

Phone:

City:

State:

ZIP Code:

Occupation:

Full Part Time

Annual income: $

Single Parent Household: Yes No

Other Adult in Household Employment Information

Other Adult Name: 

Employer Name: 

How long? 

Address: 

Phone: 

City: 

State: 

ZIP Code: 

Occupation: 

Full Part Time

Annual income: $

Children’s Information

Child Name: 

Date of Birth (MM/DD/YYYY):

1. 

   

2. 

 

3.  

 

License Daycare Provider or Preschool

Name of Facility: 

Director: 

Phone: 

Address: 

Email 

City: 

State: 

ZIP Code: 

Registered:  Yes No

Monthly Fees: $

Before/After School Information

Name of Facility:

Director:

Phone:

Address:

Email

City:

State:

Zip Code:

Registered:  Yes   No

Monthly Fees: $

Gross Annual Household Income

Your income

Spouse’s income

Other income

· Salary including tips

$

$

$

· Unemployment compensation

$

$

$

· Social Security compensation

$

$

$

· Child Support

$

$

$

· Aid for Dependent Children

$

$

$

· Alimony

$

$

$

· SSI

$

$

$

Monthly Expenses  

· Mortgage

$  

Clothing

Loans

$  

· Rent

Childcare

Credit Cards

· Food

Cable

Life Insurance

· Electricity

Car Payments

Medical Insurance

· Gas

Travel Expenses

Car Insurance

· Water

Home Telephone

 

 

· Medical

Cell Phone

Total Monthly Exp.

What dollar amount are you able to pay? $

Have you ever received Childcare Assistance from Dorcas Ministries?      Yes No

If yes, what kind?

If yes, when?

 

Please share why you are applying for financial assistance?

Other Assets or Sources of Income

   Food Stamps   Yes   No  $ 
   Medicaid for Children or Household  Yes   No
   Medicare for Children or Household  Yes   No 
   North Carolina State Voucher for Childcare   Yes   No  $ 

 

I certify that all information is true and complete to the best of my knowledge. I grant permission to Dorcas to verify this information. I agree to notify Dorcas if my financial status should change or if my child is no longer participating at the designated place for which I am receiving assistance.



(Signature will be required at time of interview.)             (Date of Signature)

To submit the application, click Yes to accept the otherwise the application will not be submitted.

I accept the Terms and Conditions:        Submit this form on-line.

FOR OFFICE USE ONLY

Date of interview: __________________  Date Processed: __________________  Date Notified: _____________________


Assistance Awarded: ___________________________________ Payable to: _____________________________________

Form: 120207