Salvation Army: Elyria(440) 323-2026716 Broad StreetElyria OH 44035 Name * First Name Last Name Email * What assistance do you need? * Spouse/Partner's Name (if applicable) Are you homeless or at risk of becoming homeless? * (Please select) Yes No Street Address * If homeless, please write "homeless" into following each address field. Apartment/Lot Number City * Zip Code * Phone * (###) ### #### Is it okay to leave you a message at the number provided? * (Please select) Yes No Date of Birth Number of Seniors (60+) in Household: * Number of Adults (18-59) in household: * Number of Children (age 17 and under) in household: * Total Gross Monthly Household Income : * Income Source(s): * Employment/self-employment SSI/SSDI Unemployment Worker's Compensation Child Support Retirement None Other: please state below If "Other" was selected above, state here: Have you applied for unemployment? * (Please select) Yes No Do you make rent or mortgage payments? * (Please select) Rent Mortgage Neither How much do you pay a month for rent/mortgage? * $ How much do you pay a month, on average, for utilities? * $ How much do you pay for any other monthly expeses? * $ Briefly describe your current assistance needs and please specify how far behind you are on any bills: * Are there any deadlines you need to meet, such as a disconnect notice or court date? Please describe. Please list the best times for the agency to call you: * Morning/afternoon/evening, or specific times. If you are currently working with a case manager, please include their name and phone number: Do you feel safe in your home? * (Please select) Yes No If no, please contact Genesis House Lorain County Safe Harbor 24 Hour Hotline: (440)244-1853 http://www.genesishouseshelter.org/ http:// What is the name of the landlord/utility company you need assistance paying? * By including my utility company or landlord name above, I understand I am giving permission for the case manager to communicate with them for up to 30 days for my billing history, where possible. * Agree Thank you!
