Page 3 - TBRA_Intake

FORM P Community Services of Northeast Texas, Inc.

560 Revised 304 E.Houston ● P.O. Box 427

MAY 27, 2017 Linden, Texas 75563

TBRA Intake Application Approved for TBRA program

Applicant Last Name Applicant First Name Date County

Physical Address City State Zip

Mailing Address (if different) City State Zip

How did you hear about this program? Are you currently homeless?

Yes No

To process your application, we need this information. We will not
move forward with your application without the following items:

► Proof of earned or unearned income (social security award letter, check stubs for the most recent two months)
► Checking account statements (most recent six months)
► Savings account statement (most recent)
► Investments (stocks, bonds, CDs, retirement accounts, pensions) if any
► Other income of any kind

Basic Household Information - List the head of household followed by all members living in the home

Household Social Security Date of Race Hispanic/ Disabled Veteran Gender Insurance
Member Number Birth Y/N Y/N
Latino Y/N Y/N

1

Education Level: □ 0-8 □ HS Grad □ GED □ 12+College □ 2 yr Grad □ 4 yr Grad

2

Education Level: □ 0-8 □ HS Grad □ GED □ 12+College □ 2 yr Grad □ 4 yr Grad

3

Education Level: □ 0-8 □ HS Grad □ GED □ 12+College □ 2 yr Grad □ 4 yr Grad

4

Education Level: □ 0-8 □ HS Grad □ GED □ 12+College □ 2 yr Grad □ 4 yr Grad

5

Education Level: □ 0-8 □ HS Grad □ GED □ 12+College □ 2 yr Grad □ 4 yr Grad

6

Education Level: □ 0-8 □ HS Grad □ GED □ 12+College □ 2 yr Grad □ 4 yr Grad

This page must accompany the TEXAS HOME PROGRAM Intake Application
Use blank pages to enter additional information.