BROKERS Care Application Form
Please complete this form to help us determine your eligibility to receive benefits.

PLEASE READ COMPLETELY BEFORE COMPLETING APPLICATION:
The questions below will only be used for Brokers Care review and WILL NOT be sent to any state or government agencies. Please be honest and accurate. We know that some of our financial help can affect what assistance you may already be receiving.Brokers Care wants to be sure to account for this so we can work alongside these services. IF we we need to cover the loss of assistance due to you getting any assistance from Brokers Care we want to be sure to account for this. That way you are not making choices over food vs. assistance from Brokers Care which can include more extensive assistance than what you may be receiving now.

* An application for assistance does not confirm nor determine that assistance will be awarded from Brokers Care and/or its affiliates. Applications are reviewed on a first come first serve basis and are not approved for assistance until all requested information is received, reviewed, and a determination is made that assistance will be awarded.
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Email *
TELL US ABOUT YOUR FAMILY
In this section we need to know more about you and your family. Please answer all questions. Include anyone that lives in your home.
Full Name (first name, last name) *
Phone number *
How many people, aside from yourself live at your address? Include anyone who lives with you regardless of age or family relation. *
Required
List the full name and ages of any dependants you care for. (Include any minors and adults/elderly) *
Are you or any members of your family/household former military? *
Honorably Discharged? *
HOUSING
This section will help us understand your immediate needs for housing and what may be needed in the future.
Do you currently have a place to live? *
If no, where are you and your family sleeping/living while not at work/school? *
If homeless, how long have you not had a residence? *
Is there an immediate need for clothing, toiletries, or medical concerns? Please provide details. *
Do you have proper identification like driver's license or state ID? *
Full address if not homeless *
Do you rent or own the home you live in? *
Are you current with your rent/mortgage payment? *
Name and contact information for landlord/mortgage company *
If behind paying rent/mortgage payment, how many months behind? *
Required
If you have a mortgage, have you contacted the mortgage company to work with them on late payments? *
What was the outcome of the contact with the mortgage company? *
Has an eviction date been provided to you? *
What is the eviction date? *
Is there any risk of your electricity, gas, or water being shut off due to non payment? *
If yes, which utilities? *
Required
Soonest estimated shut off date for any utilities listed above *
Required
INCOME
In this section we need to see how much total income is available to you and your family/household so we can better understand where we can help.
List all sources of income currently made by yourself, spouse, dependants,  household member, or minor children. (include any cash payments for work) EXAMPLE: Name of applicant, employer, rate of pay, paid weekly, bi-weekly, bi-monthly, monthly, cash paid *
Do you or any family/household members have a checking/savings account? *
Are you or any family or household members paid by direct deposit? *
List the accounts and current balances. *
CURRENT ASSISTANCE RECEIVED
In this section we need to understand what assistance you get now and what other assistance needs may not be met by traditional county, state, or federal assistance.
Are you currently receiving any assistance from resources like Section 8, SNAP, Childcare, School Lunch programs, WIC, healthcare, or from family? *
If yes to the previous question, what assistance are you receiving monthly and from what sources? (We do not want to jeopardize assistance you already receive and need this info to help us understand which types of assistance we can/need to provide to you.) *
Are all members of your household covered by some type of healthcare? *
If no, are any not covered by healthcare minor children? *
Are there any medical conditions for any family/household members not being met due to cost of medications or lack of insurance? *
If yes, provide name of family/household member and their medical need. If coverage is going to run out, include this information. *
How much is needed to properly feed your family each month? *
How close is the nearest grocery store from your home? *
Is it within walking distance of your residence? *
Is it a full grocery store or a smaller store with limited grocery items? *
Do they accept SNAP? *
Do you have access to any local food banks within 30 miles from you? *
If yes, do they have food to give? *
Are there any needs for help with baby formula? *
EDUCATION
Are any members of your household students? *
What type of student? Check all that apply. *
Required
Are uniforms required for any of the  minor aged students attending school? *
Is a lack of internet preventing attendance to school or training programs? *
Do any of your minor children require daycare? (This includes before school, after school, and any under school age) *
If you have child care in place, what daycare or individual, including family, are providing current child care? How much are you paying for that care per month? *
If you do not have child care in place now, is child care a need that would allow more time for work or education? *
What childcare would you be in need of? *
Required
ADDITIONAL QUESTIONS
This section will help us understand what additional opportunities for Brokers Care to assist with.
Would new career training be something that would help you or your adult family members build a financial future? *
Is the expense of career training preventing any of the adult household /family members from starting training or preventing a family member from working? *
Is the lack of transportation, child care, etc. preventing further career education or job growth? *
Tell us who could benefit from new training and is unable to attend training and explain what obstacle is in the way. *
Do you have dependable transportation to get to work, school, etc. ? *
Is there dependable public transportation available to you? *
If you were to use it to get to a location like work or school would it get you there within 1-2 hours? *
CURRENT EXPENSES
This section will help us understand your financial situation you are currently experiencing.
Rent/Mortgage Payment *
Electricity Bill Monthly Payment *
Water Bill Monthly Payment *
Gas Bill Monthly Payment *
Auto Payment *
If you have an auto payment is it current? *
If no, how many months behind on the car payment? *
Auto Insurance monthly payment *
Is the auto insurance and registration current for any auto owned and used to get to work or school? *
If no, when did either expire? *
Gas For Transportation *
Credit Card Payments And Balance (List all that you currently have) *
ADDITIONAL INFORMATION
This section is required. The answers will not disqualify anyone from assistance from Brokers Care.
Do you or anyone listed on this application suffer from addiction to any substances? *
Required
Do you or anyone listed on this application suffer from diagnosed or possible undiagnosed mental illness? *
Required
Are  you or any of your family members living away from each other due to being unable to care for them or not having a residence of your own? -Check all that apply *
Required
What caused your financial distress? -We know that sometimes one small event can turn a fragile financial situation into a bigger financial burden. Please share with us what happened. *
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