Assitance

APPLY FOR

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APPLICATION FOR Assistance

Please complete the form below in its entirety and click "Submit" when completed. All information given is strictly confidential. Emails and form submissions are monitored during regular business hours. Our operations director will get back to you as soon as possible. Please note that you must be a single mother with school-aged children and a resident of Fort Bend County to be eligible for assistance.

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Today's Date

Date of Birth

First Name

Last Name

Address 1

Address 2

City

Apartment #

Zip/Postal Code

Home/Cell Phone #

Work Phone #

Age

How long have you lived at this present address?

If you are completing this application on behalf of someone else, please provide the following additional information:

• Representative Name

• Position

• Phone Number

BACKGROUND

If No, Provide Status

EMPLOYMENT / RELATIONSHIP STATUS

If willing, would you be able to submit a drug screen?

Yes

If you have children, do you have a court order for child support?

Yes

If you have a court order for child support, do yu receive it consistenly?

Yes

Total Monthly Income (Include employment income, child support, alimony, dividends, etc.)

OTHER HISTORY

Who currently lives in your household? Please list all of your children.

Include the following: Name, DOB, Age, Relationship, Gender, If child, name of father?

Do you have any children with special needs? If yes, please explain.

Do you have a history of substance abuse or addiction? If yes, please explain.

Have you ever been convicted of or plead nolo contendere (no contest) to any violation of the law other than minor traffic tickets? If yes, please explain.

Do you have any criminal charges or procedures pending? If yes, please explain.

Have you ever been, or are you currently being investigated by Child Protective Services? If yes, please explain.

CURRENT STATUS

Please explain your current situation, and let us know what type of assistance you are requesting. Please also indicate if you have reliable trasportation.

Your application has successfully been submitted.