Pre-screening Application

PRE-SCREENING APPLICATION 2021

BCAP/BUDGET COUNSELING CENTER - HOMELESS ASSISTANCE PROGRAM

*ALL QUESTIONS MUST BE ANSWERED AND ALL REQUESTED DOCUMENTATION MUST BE PROVIDED*

GENERAL INFORMATION
Last Name
First Name
Middle Initial
Date
Social Security #
Date of Birth
Telephone
County
Street
City
Zip
Name of All Agencies You Are Currently Working With:
HOUSING AND INCOME
Do You Rent or Do You Own Your Home?
Are You Homeless Moving Into a Residence?
Were You Homeless Within the Last 45 Days?
Total Number of Persons Over the Age of 18 Residing in This Household
Total Number of Children Under the Age of 18 Residing in This Household
Are Any Members of This Household a U.S. Veteran?
Total Household Income (Per Month)

(Mark all that apply)

CURRENT UTILITIES
Type of Utility
Monthly Payment
Amount Deliquent
Deposit Needed
Electric
Gas/Propane
Water
Sewer/Trash
REQUEST FOR ASSISTANCE
Amount (If Known)
Amount
REASON FOR ASSISTANCE
DOCUMENTS

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Current State ID
Proof of Income for 202 (Last 30 Days)
Denial Letter From Welfare Regarding Rental Assistance
2021 Food Stamp Printout Providing Amount Received
Social Security Cards, Medical Cards for All Household Members and Access Card
Lease
Eviction Notice and/or District Justice Notice
Most Recent Utility Bill Which Shows You Are 20 Days or More Behind
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