Step 1 of 5 20% Head of HouseholdFirst Name* Middle Initial Last Name* Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneEmail Household Members(Includes everyone living at the same address) Household MemberName First Last Sex Male Female Birthdate Month Day Year Relationship Race School Phone Add household memberRemove household member Household Income Data Household MemberName First Last Income TypeEnter monthly amount into the appropriate fieldPaycheckTANFUnemploymentSNAPSocial SecuritySocial Security DisabilityOtherAdd household memberRemove household memberIf you entered any "other" income, please explain Rent InformationHousing DevelopmentSelect BelowEstella MaxeyKate RossMart Housing AuthoritySouth TerraceSection 8Monthly RentAre you in arrears with your rent? Yes No Don't Know What is the total amount of your arrears?Do you give WHA permission to share your financial information with us (WPMG)? Yes No Are you willing to resolve your arrears at this time? Yes, I would like to hear information on how to resolve my rent arrears. No Will you be receiving a stimulus check? Yes No Are you willing to use any part of your stimulus check to resolve your rent arrears? Yes, I would like to use a portion of my stimulus check. No, I don’t want to use my stimulus check. Do you want assistance in resolving your rent arrears situation? Yes No Select a Plan Plan A: Down payment & monthly installments Plan B: Monthly installments (no down payment) I would like to make a down payment ofwithin the next(Timeframe)Please SelectDaysWeeksMonthsI will pay this amount each month in addition to my regular monthly payment: Income & EmploymentIncome and Employment Did you lose income due to COVID-19? Yes No Was your loss of income due to having lost employment due to COVID-19? Yes No Do you want to return to work? Yes No Do you want the same type of job or do you want a different type of job? Same Different Job Types Accounting/Finance Advertising/Public Relations Aerospace/Aviation Arts/Entertainment/Publishing Automotive Banking/Mortgage Business Development Business Opportunity Clerical/Administrative Construction/Facilities Consumer Goods Customer Service Education/Training Energy/Utilities Engineering Government/Military Green Healthcare Hospitality/Travel Human Resources Installation/Maintenance Insurance Internet Job Search Aids Law Enforcement/Security Legal Management/Executive Manufacturing/Operations Marketing Non-Profit/Volunteer Pharmaceutical/Biotech Professional Services QA/Quality Control Real Estate Restaurant/Food Service Retail Sales Science/Research Skilled Labor Technology Telecommunications Transportation/Logistics Other Are you interested in attending any type of virtual classes to prepare you for a job? Yes No Select all classes you would like to attend Stress Job Search Resume Writing Interviewing Job Fair Prep Finances Are you registered in WorkinTexas? Yes No Case NotesSignature __________________________________________________________ Date ____________________________NameThis field is for validation purposes and should be left unchanged. Δ
