Chamblee COVID-19 Relief Fund Application (English)

Applicant Information

Head of House*

First Middle Last Maiden

SSN

Last 5 digits

Date of Birth*

MM

DD

YYYY

Gender*

Race*

American Indian/Alaskan Native
Asian
African American
Caucasian
Hispanic/Latino
Native Hawaiian/Pacific Islander
Unknown

Email

Address*

Street Address Address Line 2 City State ZIP Code

How long at this address?

Apartment Complex Name

If applicable

Primary Phone*

Other Phone

Marital Status*

Other Information

Current Employer (or most recent employer, if not currently working)*

Full-time
Part-time

How long employed:

Previous Employer

How long employed:

Church Affiliation (if any)

This does not affect your application status.

Spouse / Other Adult (if applicable)

Name

First Middle Last

SSN

Last 5 digits

Date of Birth

MM

DD

YYYY

Gender

Race

American Indian/Alaskan Native
Asian
African American
Caucasian
Hispanic/Latino
Native Hawaiian/Pacific Islander
Unknown

Household Make-Up

Total # People in Household*

How many children in household?*

Are there others in household (not dependent children)?*

Please list first and last name, date of birth and gender for each additional member in your household. (Do not include dependent children here. You can enter their information later.)

Child 1

Name

First Last

Date of Birth

MM

DD

YYYY

Gender

Children's Information

Child 1

First Last

Date of Birth

MM

DD

YYYY

Gender

Child 2

First Last

Date of Birth

MM

DD

YYYY

Gender

Children's Information

Child 1

First Last

Date of Birth

MM

DD

YYYY

Gender

Child 2

First Last

Date of Birth

MM

DD

YYYY

Gender

Child 3

First Last

Date of Birth

MM

DD

YYYY

Gender

Children's Information

Child 1

First Last

Date of Birth

MM

DD

YYYY

Gender

Child 2

First Last

Date of Birth

MM

DD

YYYY

Gender

Child 3

First Last

Date of Birth

MM

DD

YYYY

Gender

Child 4

First Last

Date of Birth

MM

DD

YYYY

Gender

Children's Information

Child 1

First Last

Date of Birth

MM

DD

YYYY

Gender

Child 2

First Last

Date of Birth

MM

DD

YYYY

Gender

Child 3

First Last

Date of Birth

MM

DD

YYYY

Gender

Child 4

First Last

Date of Birth

MM

DD

YYYY

Gender

Child 5

First Last

Date of Birth

MM

DD

YYYY

Gender

Children's Information

Child 1

First Last

Date of Birth

MM

DD

YYYY

Gender

Child 2

First Last

Date of Birth

MM

DD

YYYY

Gender

Child 3

First Last

Date of Birth

MM

DD

YYYY

Gender

Child 4

First Last

Date of Birth

MM

DD

YYYY

Gender

Child 5

First Last

Date of Birth

MM

DD

YYYY

Gender

Child 6

First Last

Date of Birth

MM

DD

YYYY

Gender

If you have more than 6 children living in your household, please finish listing out the rest of the names below:

Purpose of Request & Amount

Helped by St. Vincent de Paul Georgia before?*

Yes
No

Please tell us about your situation and the amount you are requesting*

Include the circumstances that led you to this situation and other details pertaining to your need for assistance.

I confirm that COVID-19 has impacted my emergency situation.*

Please select reason below:

Loss of employment (Layoff/furlough)
Reduction of wages or loss of working hours
Positive COVID-19 test for myself or a family member.
Loss of employment due to lack of childcare
Loss of employment due to children at home doing virtual learning
Loss of wages/employment due to being of a COVID-19 high-risk population
Other: to be determined (Consultation with caseworker will determine eligibility.)

Please upload documentation of COVID-19 impact:

Example: Loss of employment/termination letter, unemployment statement, positive covid-19 test, paystubs to show loss of wages, etc. *All documentation must have applicant's name on it. (jpg, gif, png, pdf accepted). If you cannot upload this now, you may be asked to provide it to your caseworker once assigned.

Medicare*

Yes
No

Medicaid*

Yes
No

SNAP (Food Stamps)*

Yes
No

WIC*

Yes
No

Veteran*

Yes
No

Income (monthly)

Alimony

Child Support

Employment

Spouse/Roommate Employment

Food Stamps

Retirement/Pension

Social Security

SSI, SSD

TANF (AFDC)

Unemployment

Veteran Benefits

Workers' Compensation

Other

Total Income

Expenses (monthly)

Alimony

Child Support

Child Care

Food

Electricity

Water/Sewer

Natural Gas/Propane/Heating Oil

Telephone

Rent/Mortgage

Prescriptions/Medical

Transportation/Car Payments

Insurance (Auto, Health, Dental, Life)

Loans/Credit Card

Cable/Satellite/Internet

Other

Total Expenses

Please list any outstanding bills you currently have:

Please upload documentation of your outstanding bill:

(Late/eviction Notice, Mortgage notice, Late Utility Bill) *All documentation must have applicant's name on it. (jpg, gif, png, pdf accepted). If you cannot upload this now, you may be asked to provide it to your caseworker once assigned.

Drop files here or

Please upload proof of residency:

(copy of a utility bill, signed lease copy, etc. that shows you are a resident of Chamblee). *The document should have your name and address on it. (jpg, gif, png, pdf accepted). If you cannot upload this now, you may be asked to provide it to your caseworker once assigned.

Drop files here or

Agencies applied to within the last 12 months (Please give info on all that apply):

Name of Agency

Purpose of Request

Amount Given

Date

MM

DD

YYYY

Name of Agency

Purpose of Request

Amount Given

Date

MM

DD

YYYY

Authorization For Release of Confidential Information:

In consideration of the services to be undertaken or rendered on my behalf by the Society of St. Vincent de Paul, its members, agents or affiliated organizations (hereinafter referred to as "SVdP", I, the undersigned hereby authorize SVdP to receive, from any and all sources, and to release to any person or organization, any confidential information regarding me which may be necessary or useful to SVdP and the Chamblee COVID-19 Relief Fund in relation to the services to be rendered. I hereby release SVdP and it's community partners, from all liability in any way related to the receipt and/or release of said confidential information. I further understand that the release of this information does not guarantee that assistance will be provided. but that without such information my case cannot be presented to the Society of St. Vincent de Paul and Chamblee COVID-19 Relief Fund for consideration. This release expires sixty (365) days after the Undersigned signature date.*

I accept

Signature*

I would be willing to share my story of how the Chamblee COVID-19 Relief Fund helped me.

I give St. Vincent de Paul Georgia permission to contact me for future updates.

Email

This field is for validation purposes and should be left unchanged.

Please complete the application below to the best of your ability and a caseworker will be in touch with you.

Applicant Information

Other Information

Spouse / Other Adult (if applicable)

Household Make-Up

Child 1

Children's Information

Children's Information

Children's Information

Children's Information

Children's Information

Purpose of Request & Amount

Income (monthly)

Expenses (monthly)

Agencies applied to within the last 12 months (Please give info on all that apply):

Authorization For Release of Confidential Information: