Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. 7. gets Head Application must be entirely filled out to be considered. Please upload Photo ID for all adults Drag & Drop Files, Choose Files to Upload You can upload up to 2 files. Please upload Copies of pay stubs or other income sources Drag & Drop Files, Choose Files to Upload You can upload up to 5 files. Please upload Copies of outstanding bills such as utilities, water, etc Drag & Drop Files, Choose Files to Upload You can upload up to 9 files. #1 – Household Demographics Head of Household Name *Email *Date *Phone *Household Occupants *Head of Household Date of Birth *Current Address *How long have you lived there? *Landlord’s Name *Landlord’s Phone Number *Landlord’s Address *Where did you live before? * Household Occupants Information NameBirth DateRelationship2. Name2. Birth Date2. Relationship3. Name3. Birth Date3. Relationship4. Name4. Birth Date4. Relationship5. Name5. Birth Date5. Relationship6. Name6. Birth Date6. Relationship7. Name7. Birth Date7. Relationship#2 – Employment Are you and/or anyone in your household employed for pay?YesNoAre you employed:Part-timeFull TimeUnemployed seeking workUnable to work Employment Details EmployerWhat is your position?Hours per weekWages per weekIf unemployed, please explain.Does your current household income provide enough income to support yourself & your family?YesNo #3 – Financial Information Who gets Child SupportIncome SourceHow much?When receivedWho gets Employer WagesIncome SourceHow much?When receivedWho gets a Pension / RetirementIncome SourceHow much?When receivedWho gets Social SecurityIncome SourceHow much?When receivedWho gets SSDIIncome SourceHow much?When receivedWho gets SSIIncome SourceHow much?When receivedWho gets Unemployment BenefitIncome SourceHow much?When receivedWho gets Other IncomeIncome SourceHow much?When receivedWhat is your total NET monthly income? (Take home pay?) #4 – Government Benefits Are you receiving any government benefits? YesNoFood stamps per monthWIC per monthMedical Assistance forFinancial Assistance How much do you receive from each of these? Salvation ArmySt. Vincent de PaulEnergy AssistanceHome Town MissionWatertown Family AidOtherHave you received assistance from Crossroads in the past?YesNoIf yes, when did you receive the assistance?#5 – Monthly Expenses Please give a dollar amount for the following monthly expenses. If you have a back amount that is owed, please list that amount in the second column. Current Monthly RentBalance OwedCurrent Monthly Car paymentBalance OwedCurrent Monthly Medical ExpenseBalance OwedCurrent Monthly Electric / Heat ExpenseBalance OwedCurrent Monthly Water ExpenseBalance OwedCurrent Monthly Telephone ExpenseBalance OwedCurrent Monthly Cable / Internet ExpenseBalance OwedCurrent Monthly Groceries ExpenseBalance OwedCurrent Monthly Child Care ExpenseBalance OwedCurrent Monthly Loan ExpenseBalance OwedCurrent Monthly Credit Cards ExpenseBalance OwedCurrent Monthly Fines ExpenseBalance OwedCurrent Monthly Miscellaneous ExpenseBalance OwedHealth Do you have any current health issues?YesNoIf yes, please explain:Why are you applying for assistance today? How much money are you requesting?Please describe the events that happened to cause you needing assistance.What have you already done to help with your difficulties?AUTHORIZATION FOR RELEASE OF INFORMATION This authorization allows Crossroads committee to release/obtain/exchange information with any of the following organizations and includes our corresponding with your landlord. Watertown Unified School District Watertown Head Start Watertown Dept. of Public Health St. Vincent de Paul Salvation Army ChurchPlease add the church nameAuthorizationTyping my name here is my signatureToday's DateAlternate Phone – In case we cannot reach you at the number given, is there another number where we might be able to get in contact with you?NamePhoneCustom Captcha * = Submit