Pre-Application Intake Form

NOTE: By completing this form, you are submitting a Pre-Application Intake to the Warren Township Trustee of Marion County. Please submit only one (1) application per thirty (30) day period. Duplicate applications within a thirty (30) day period will be automatically deleted from our system. You may expect a response time of 7-10 days. Thank you for your patience.

Have you completed this form within the last thirty (30 days? *

• Yes
• No

IF YOU ANSWERED YES ABOVE STOP HERE

Client Name *

First

Last

Client Date of Birth *

Client Address *

Client Telephone Number *

Client Email Address *

Re-enter Client Email Address *

Do you have any dependents? *

• Yes
• No

If yes, please provide details: the number of dependents

pay you Who

If yes, please provide details: the ages of each dependent (17 and younger)

Who do you bank with? *

Do you have a car payment? *

• Yes
• No

If yes, what is the amount you pay each month?

Are you a resident of Warren Township? *

• Yes
• No
• Not sure

Are you a United States citizen? *

• Yes
• No
• Qualified Alien (as defined under 8 U.S.C. 1641)
• Someone in my household adult(s) or child(ren) is not a US citizen or Qualified Alien

Are there any other adults in the home OR listed on the lease or mortgage? *

• Yes
• No

If yes, please provide details for other adult(s):

• Not in the home, but listed on the lease or mortgage
• In the home and listed on the lease or mortgage
• In the home and not listed on the lease or mortgage

Do you receive government housing assistance (i.e. Section 8, Public/Low Income Housing, HUD, Section 42)? *

• Yes
• No

How much is your base rent? *

How many bedrooms are in your home? *

What type of assistance are you seeking? (Select all that apply) *

• Housing Assistance - Rent/Mortgage
• Emergency Shelter
• Utility
• Clothing
• Diapers
• Bus Pass
• Household Items
• Food
• Burial or Cremation
• Eligible Medical Services
• Other

If you chose other, please explain.

Please describe the events that have taken place in the past 90 days resulting in your household's need for emergency assistance. *

What is your current employment status? *

• Employed Full Time
• Employed Part Time
• Unemployed
• Student
• Retired
• Self Employed
• Receiving Unemployment
• PRN (as needed)
• Other

Could you please explain your current employment status? If you're unemployed, when was the last time you worked and what led to your departure from that job? If you're currently employed, do you receive payment on a weekly, bi-weekly, daily, or per-job basis? Additionally, we would appreciate it if you could share more about your work history and any challenges you may be facing in your current or past roles. *

What is your approximate monthly income? (Please provide your total income from ALL SOURCES. (i.e. Wages, Social Security/Disability, Pension, Retirement, Survivor Benefits, etc.) *

Is there any additional information you would like to share? For instance, details about other adults in the household or any other factors we should be aware of. *

• Yes
• No

If you answered Yes above, please explain.

Do you need an Interpreter? *

• Spanish
• Haitian - Creole
• ASL
• Other
• No

Would you prefer to receive your appointment details and paperwork by mail or email? If mailed, all required documents will be highlighted in yellow for your convenience. If emailed, please ensure you have access to a printer to print the necessary documents for your appointment. *

• Please email my documents and appointment
• Please mail my documents and appointment
• Please email and mail my documents and appointment

If you have submitted this application within the last thirty (30) days DO NOT SUBMIT TODAY. Duplicate applications within a thirty (30) day period will be automatically deleted from our system.

Today's Date *

Submit