Client Intake Form

    

Co-Application/Emergency Contact

    
YesNo
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Housing Information

$
Dollars
Cents

Insurance Information

$
Dollars
Cents

Source of Assistance

Source of Assistance
Amount Granted
Amount Unspent

Personal Assets (Please provide 3 months bank statements)

GoFund Me

Buddhist Tzu Chi Foundation

Risk Assessment

(please mark all that apply) 

Reported Needs

Client Reported Damage to Primary Residence

Current Dwelling Status

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