APPLY FOR ASSISTANCE

Application for Assistance

Please complete this form 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 intake coordinator 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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If you are completing this application on behalf of someone else, please provide the following additional information:

• Representative Name

• Position

• Phone Number

BACKGROUND

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EMPLOYMENT/RELATIONSHIP STATUS

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If willing, would you be able to submit a drug screen?
If you have children, do you have a court order for child support?
If you have a court order for child support, do you receive it consistently?

(Include Employment Income, Child Support, Alimony, Dividends, etc.)

OTHER HISTORY

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

If yes, please explain.

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If yes, please explain.

If yes, please explain.

If yes, please explain.

If yes, please explain.

CURRENT STATUS

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