The Salvation Army Christmas Application
Registering for The Salvation Army, Holiday and Christmas Assistance 2014. WHO do we help? Households within Grand Traverse & Leelanau Counties only. Households that have not applied for holiday assistance elsewhere. WHAT assistance is available? Thanksgiving Food Basket & Turkey (last day to apply is Thursday, November 13) Christmas Toy Shop ( children ages 0 - 17 & Food Voucher) NEW: Adopt - a - Teen program o Gifts for Teens 13 - 17 provided by sponsors from the community o A "Wish List" of reasonable gift suggestions is given by you NEW: Adopt a Senior ages 62+ o Gifts & Food Vouchers provided by sponsors from the community o Food/Food Voucher provided by sponsors from the community o A "Wish List" of reasonable gift suggestions is given by you WHEN can I apply? October 28 - November 6 o Tuesdays and Thursdays (1-3 pm) November 11 - December 4 (except Nov 20 & 27) o Tuesdays and Thursdays (1 - 3 pm and 5:30 - 7:30pm) Thanksgiving Assistance Program closes at day's end on November 13, 2014 Christmas Assistance Program closes at day's end on December 4, 2014 WHERE can I apply? The Salvation Army Community Center, 1239 Barlow Street, Traverse City, MI 49686 Call 231.946.4644 with questions HOW do I qualify for assistance? Bring the following with you to apply: Picture IDs: o Picture ID for all household members ages 18 and up is required. o Identification must display current physical address. Social Security Cards: o Social security card is required for all household members. o A birth certificate will be accepted in lieu of social security card for newborns. Verification of Income o Verification of income is required; it must display all household income for the last 30 days o Tax forms or a bank statement is accepted to verify the income for the self-employed o Families up to the 150 percentile of the 2014 federal poverty level are eligible for assistance. Verification of Expenses: o Verification of all household expenses required. o Documents may include: Rent/Mortgage receipts; electric/gas/propane/water bills, car payment, insurance, child support, insurance, medical bills, etc.
The Salvation Army
1239 Barlow Street, Traverse City
Phone 231.946.4644
The Salvation Army Holiday Assistance Application - 2014 Please PRINT all information clearly. Thank you!
Today’s Date: ____/____/______
List all ADULTS in household: M I
First Name:
ID Letter
SS#
(Last 4 digits only!)
Full Last Name:
Date of Birth:
Age
Gender
Head of Household
____/____/______
Spouse/ Other
____/____/______
Other
____/____/______
M F
Other
____/____/______
M F
List all CHILDREN in Household: Relationship to Head of Household (ie. Son)
(Office Use)
M F
M F
IMPORTANT! PARENTS / GUARDIANS MUST HAVE CUSTODY OF CHILDREN LISTED BELOW.
First Name:
M I
SS# (Last 4 digits only!)
Full Last Name:
ID Letter (Office Use)
Date of Birth:
Age
Gender
____/____/______
M F
____/____/______
M F
____/____/______
M F
____/____/______
M F
____/____/______
M F
CONTACT INFORMATION Primary language spoken in home:
Secondary language spoken in home:
Mailing Address:
City:
Zip Code:
Apartment or Lot #:
Township:
County:
Daytime Phone #:
(
)_____________-_____________
Home
Cell
Work
Message
E-mail Address: Have you applied for Christmas Assistance with another agency? Yes No
If so, where?
PLEASE INDICATE WHICH HOLIDAY ASSISTANCE PROGRAMS YOU ARE APPLYING FOR: _____ Thanksgiving Food Basket & Turkey _____ Christmas Toy Shop (Children up to age 17) _____ Christmas Food Voucher _____ Adopt-a-Teen Program (Teens ages 13-17) (Fill out a Wish List Form. IF SELECTED, gifts will be provided for the teen by a sponsor from the community) _____ Adopt-a-Senior Program (Seniors ages 62+) (Fill out a Wish List Form. IF SELECTED, gifts & food will be provided for the senior by a sponsor from the community) (PLEASE TURN PAPER OVER TO COMPLETE) ACCESS ID #______________________
INCOME
EXPENSES Salary:
$
Rent/Mortgage:
$
SSI/SSDI:
$
Heat/Gas:
$
Child Support:
$
Light/Electricity:
$
State DHS/DCF Grant:
$
Telephone/Internet:
$
Food Stamps:
$
Food :
$
Other
$
Child Support:
$
Other
$ $
Car Payment:
$
Insurance:
$
Other:
$
Other $ Other Other
$
Other:
$
Other
$
$
TOTAL HOUSEHOLD INCOME
$
Other TOTAL HOUSEHOLD EXPENSES
$
Special circumstances? (please describe):
Please initial:
Statements I swear that the information provided on this application is true and complete, that it is subject to verification, and if found to be fraudulent, my household may be disqualified from receiving Holiday Assistance from The Salvation Army. I give permission for The Salvation Army to consult with other service providers about Holiday Assistance provided to my household. I give permission for The Salvation Army to share my household’s first names, ages, genders, and gift suggestions with a family or organization who may wish to sponsor my household for Holiday Assistance.
I will not seek assistance from other agencies for Holiday Assistance. I understand that my household may be disqualified from all Holiday Assistance if I seek assistance from other agencies Applicant’s signature: ___________________________________________________________________Date: _________________________ Volunteer / staff signature: _______________________________________________________________ Date: _________________________
OFFICE USE ONLY: MISSING INFORMATION
Date Received
By Whom?
Date
Completed by whom? AT THE TIME OF INITIAL INTERVIEW
Task Verify Signed Release of Information (ROI) Enter into Access database Print form 1 copy to client, 1 copy attached to application, ROI, & Adoption Wish list (if eligible)
ADOPT-A-TEEN/SENIOR Check Adopt-Teen/Senior eligibility If eligible, assign to sponsor Send letter w/ new appt. times FURTHER PROCESSING Enter into Community database Enter into ServicePoint
The Salvation Army
1239 Barlow Street, Traverse City
Phone 231.946.4644
The Salvation Army Holiday Assistance Application - 2014 Please PRINT all information clearly. Thank you!
Today’s Date: ____/____/______
List all ADULTS in household: M I
First Name:
ID Letter
SS#
(Last 4 digits only!)
Full Last Name:
Date of Birth:
Age
Gender
Head of Household
____/____/______
Spouse/ Other
____/____/______
Other
____/____/______
M F
Other
____/____/______
M F
List all CHILDREN in Household: Relationship to Head of Household (ie. Son)
(Office Use)
M F
M F
IMPORTANT! PARENTS / GUARDIANS MUST HAVE CUSTODY OF CHILDREN LISTED BELOW.
First Name:
M I
SS# (Last 4 digits only!)
Full Last Name:
ID Letter (Office Use)
Date of Birth:
Age
Gender
____/____/______
M F
____/____/______
M F
____/____/______
M F
____/____/______
M F
____/____/______
M F
CONTACT INFORMATION Primary language spoken in home:
Secondary language spoken in home:
Mailing Address:
City:
Zip Code:
Apartment or Lot #:
Township:
County:
Daytime Phone #:
(
)_____________-_____________
Home
Cell
Work
Message
E-mail Address: Have you applied for Christmas Assistance with another agency? Yes No
If so, where?
PLEASE INDICATE WHICH HOLIDAY ASSISTANCE PROGRAMS YOU ARE APPLYING FOR: _____ Thanksgiving Food Basket & Turkey _____ Christmas Toy Shop (Children up to age 17) _____ Christmas Food Voucher _____ Adopt-a-Teen Program (Teens ages 13-17) (Fill out a Wish List Form. IF SELECTED, gifts will be provided for the teen by a sponsor from the community) _____ Adopt-a-Senior Program (Seniors ages 62+) (Fill out a Wish List Form. IF SELECTED, gifts & food will be provided for the senior by a sponsor from the community) (PLEASE TURN PAPER OVER TO COMPLETE) ACCESS ID #______________________
INCOME
EXPENSES Salary:
$
Rent/Mortgage:
$
SSI/SSDI:
$
Heat/Gas:
$
Child Support:
$
Light/Electricity:
$
State DHS/DCF Grant:
$
Telephone/Internet:
$
Food Stamps:
$
Food :
$
Other
$
Child Support:
$
Other
$ $
Car Payment:
$
Insurance:
$
Other:
$
Other $ Other Other
$
Other:
$
Other
$
$
TOTAL HOUSEHOLD INCOME
$
Other TOTAL HOUSEHOLD EXPENSES
$
Special circumstances? (please describe):
Please initial:
Statements I swear that the information provided on this application is true and complete, that it is subject to verification, and if found to be fraudulent, my household may be disqualified from receiving Holiday Assistance from The Salvation Army. I give permission for The Salvation Army to consult with other service providers about Holiday Assistance provided to my household. I give permission for The Salvation Army to share my household’s first names, ages, genders, and gift suggestions with a family or organization who may wish to sponsor my household for Holiday Assistance.
I will not seek assistance from other agencies for Holiday Assistance. I understand that my household may be disqualified from all Holiday Assistance if I seek assistance from other agencies Applicant’s signature: ___________________________________________________________________Date: _________________________ Volunteer / staff signature: _______________________________________________________________ Date: _________________________
OFFICE USE ONLY: MISSING INFORMATION
Date Received
By Whom?
Date
Completed by whom? AT THE TIME OF INITIAL INTERVIEW
Task Verify Signed Release of Information (ROI) Enter into Access database Print form 1 copy to client, 1 copy attached to application, ROI, & Adoption Wish list (if eligible)
ADOPT-A-TEEN/SENIOR Check Adopt-Teen/Senior eligibility If eligible, assign to sponsor Send letter w/ new appt. times FURTHER PROCESSING Enter into Community database Enter into ServicePoint
