Name
First Name
Last Name
Phone
(###)
###
####
Email Address
Current Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Previous Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Housing
What is your housing status?
Marital Status
What is your marital status?
Income Status
What is your income status?
Employment Status
What is your employment status?
Life insurance
Do you have life insurance?
Other Insurance
Do you have another type of insurance?
Holdings
Do you have any investment holdings? (stocks, bonds, CD's, IRA's)
Cash on Hand
Do you have any cash on hand?
If YES, give amount?
Checking Account
Do you have a checking account?
Savings Account
Do you have a savings accounts?
Claims
Does anyone in the household have any claims, including lawsuits, against a person, insurance company, employer or government agency from which you (they) expect to receive a recovery (money)?
Property
Do you own any property?
Number of Years Owned
Name of Apartment Complex or Landlord
Address of Complex or Landlord
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
What Date Did You Move Into This Rental Unit
MM
DD
YYYY
Monthly Rate Amount
Is Anyone In the Household Related to the Landlord
YES
NO
Are Utilities Included?
If Utilities Are Included, List Which Ones
Your Most Recent Employer
Date You Started Work There
MM
DD
YYYY
Date You Last Worked There
MM
DD
YYYY
Reason For Not Working Now
2nd Most Recent Employer
Date You Started Work There
MM
DD
YYYY
Date You Last Worked There
MM
DD
YYYY
Reason For Not Working Now
Serial Number
Enlistment Date
MM
DD
YYYY
Branch of Service
Discharge Date
MM
DD
YYYY
Is Everyone In The Household a U.S. Citizen?
If No Please Explain Status By Which You Are In the U.S.
List Household Members' Relatives (parents, brothers, sisters, grandparents, aunts, uncles) Including "Step" Relatives.
Include Full Name, Address, Phone and How they have helped or if they are willing to help. For Example:
Jane Doe - 123 Berrywood St. Town, Indiana - 812.345.6789 - provides rent money occasionally
If There Is a Minor In the Home,Is Child Support Ordered For Them By A Court?
If NOT, Will You Go To Court To Get Support?
If NO, Explain:
Are You Receiving Child Support?
If YES, how much?
Name of Child(ren)'s Other Parent
First Name
Last Name
Address of Child(ren)'s Other Parent If Not In Household
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Have You Or Someone In The Household Been Helped From Any Other Source Such As Churches, Multi-Service Centers or Friends Whom You Have Not Already Listed On This Form?
If YES, who, how much & when?
List Current Debt of All Household Members
Please Include : Amount of Debts, Date Purchased, Name of Creditor, Items Purchased, Value, Amount Paid, Last Pay Date
For Example:
Jane Doe – 2/12/2012, IN Bank, Ford Focus, $12,000 , $5,000, 7/10,2018
Luis Huda – 4/5/2017, IN Bank, Loan, $5,000, $2,000, 6/5/2018
EXPENSE INFORMATION
List Below Any Payments Made By Any Household Member to Any Source In the Last Thirty (30) Days
Please Include: Amount, Paid To, Due Date
For Example:
$500 – Babysitter Ann – 8/10/18
What Do You Owe Today On Your Rent or Mortgage?
What Do You Owe Today On Your Utilities?
Electricity?
Gas and Heating?
Water?
Cable?
Telephone?
Sewer?
Trash Removal?
Other?
Are Any Of These Bills In Someone Else's Name?
If YES, which ones and whose name?
What Is Your Reason For Asking for Trustee Helps?
Has There Been an Emergency or Extraordinary Circumstance You Wish the Trustee to Consider In Your Application
If YES, explain:
Specifically, What Are You Asking For Help With Today?
Subsidized Sec.8, HUB, or other Public Housing?
If YES, What Date Did You Apply?
MM
DD
YYYY
If YES, What Amount Did You Receive?T
Utility Allotment
If YES, What Date Did You Apply?
MM
DD
YYYY
If YES, What Amount Did You Receive?
Food Stamps
If YES, What Date Did You Apply?
MM
DD
YYYY
If YES, What Amount Did You Receive?
AFDC Welfare
AFDC Welfare Date Applied
If YES, What Date Did You Apply?
MM
DD
YYYY
If YES, What Amount Did You Receive?
Other Trustee Office
If YES, What Date Did You Apply?
MM
DD
YYYY
If YES, What Amount Did You Receive?
Social Security (any type)
If YES, What Date Did You Apply?
MM
DD
YYYY
If YES, What Amount Did You Receive?
V.A. Benefits (any type)
If YES, What Date Did You Apply?
MM
DD
YYYY
If YES, What Amount Did You Receive?
EAP Utility Assistance
If YES, What Date Did You Apply?
MM
DD
YYYY
If YES, What Amount Did You Receive?
FEMA Funds
If YES, What Date Did You Apply?
MM
DD
YYYY
If YES, What Amount Did You Receive?48
Unemployment Benefits
If YES, What Date Did You Apply?
MM
DD
YYYY
If YES, What Amount Did You Receive?
Grants/Loans
If YES, What Date Did You Apply?
MM
DD
YYYY
If YES, What Amount Did You Receive?
Any Other Type of Help
If YES, What Date Did You Apply?
MM
DD
YYYY
If YES, What Amount Did You Receive?
Has Anyone In the Household Been Termintated From, Refused, or Had AFDC Payments Reduces?
If YES, why?
Has Anyone In The Household Ever Been Convicted of Welfare Fraud Under IC 35-43-5-7?
If YES, when and where?
PERSON 1 FULL NAME
First Name
Last Name
PERSON 1 RELATIONSHIP
PERSON 1 DATE OF BIRTH
MM
DD
YYYY
PERSON 1 INCOME SOURCE
PERSON 1 DIGITAL SIGNATURE
PERSON 2 FULL NAME
PERSON 2 RELATIONSHIP
PERSON 2 DATE OF BIRTH
MM
DD
YYYY
PERSON 2 INCOME SOURCE
PERSON 2 DIGITAL SIGNATURE
PERSON 3 FULL NAME
First Name
Last Name
PERSON 3 RELATIONSHIP
PERSON 3 DATE OF BIRTH
MM
DD
YYYY
PERSON 3 SOCIAL SECURITY
PERSON 3 INCOME SOURCE
PERSON 3 DIGITAL SIGNATURE
PERSON 4 FULL NAME
First Name
Last Name
PERSON 4 RELATIONSHIP
PERSON 4 DATE OF BIRTH
MM
DD
YYYY
PERSON 4 INCOME SOURCE
PERSON 4 DIGITAL SIGNATURE
PERSON 5 Full Name
First Name
Last Name
PERSON 5 RELATIONSHIP
Yourself
Child
Spouse
Relative
Room Mate
Other Adult
PERSON 5 DATE OF BIRTH
MM
DD
YYYY
PERSON 5 INCOME SOURCE
PERSON 5 DIGITAL SIGNATURE
Vehicle 1 Type
Vehicle 1 Make & Model
Vehicle 2 Type
Vehicle 2 Make & Model
Vehicle 3 Type
Vehicle 3 Make & Model