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CCC Assistance Application
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* Indicates required question
Full Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Race
Your answer
Gender
Female
Male
Prefer not to say
Clear selection
Address (please include city)
*
Your answer
Phone Number (indicate type, mobile, home, work)
*
Your answer
Additional Numbers to reach you
Your answer
Email Address
*
Your answer
Family Status
*
Single
Married
Seperated
Divorced
Widowed
Other Persons Living with You (include name, date of birth, and relationship)
*
Your answer
Please Select All Assistance Recieved
*
Disability SSI
Handicap Aids
Mobility
Learning Impairment
Speech Impairment
Visual Impairement
None of the Above
Required
Have you worked with Social Services?
*
Camden Social services
Pasquotank Social Services
Perquimans Social Services
Health Department
I have not worked with any of the above agencies
Do you recieve help from any of the following agencies?
*
Medicaid
NCHC (North CArolina Health Choice)
WFFA (Work First Family Assistance)
Food Stamps
Section 8 Housing
EIC
WIC
SSI/Disability
None of the above
Required
Please indicate Food Stamp amount if selected
Your answer
Please indicate SSI/Disability amount if selected
Your answer
Type of assistance you need and reason
*
Your answer
What have you done to address these issues?
*
Your answer
What agencies have you contacted and when?
*
Your answer
Why is this request considered a temporary gap service and what will be different next month?
*
Your answer
Who referred you?
*
Your answer
Employment
*
Full Time
Part Time
Temporary
Seasonal
Unemployed
Employer Name/Phone/Address
*
Your answer
Additional Employment/Employer (name/phone/address)
*
Your answer
If unemployed what is your last date of employment
*
Your answer
Morgage/Rent Amount
*
Your answer
Car/Transportation Expenses
*
Your answer
Power/Gas/Water Expenses
*
Your answer
Food Expenses
*
Your answer
Other Expenses (cell, cable, etc) please list with amounts
*
Your answer
Please provide your income amount either weekly, biweekly, or monthly. If you receive disability please indicate that.
*
Your answer
Have you received assistance from other agencies in the last 6 months for the same request? If yes please give the agency.
*
Your answer
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