Our Community Cares - Assistance Application-Our Community Cares

Our Community Cares - Assistance Application

Supporting Residents in need in Columbia County

First Name

Middle Name

Last Name

Maiden Name

Date of Birth

Age

Place of Birth

Gender

Male

Female

Other

Primary Phone Number

Emergency Contact

Emergency Contact Phone #

Current or Most Recent Mailing Address

Are you currently staying there?

YES

How long at this address?

Physical address if different

Have you ever received services under another name?

YES

If yes, what name?

Have you ever received services with another Social Security number?

YES

If yes, what number?

Have you or your spouse ever served in the military?

YES

If yes, what branch?

Can you provide a copy of your DD214?

YES

Is it filed with the County Clerk?

YES

Employment status

Full time

Part time

Not Applicable

Are you disabled?

YES

If yes, how long?

Are you (and your dependent children) capable of self care?

YES

Yes with assistance

Disability Type: Check all that apply. Indicate if it is expected to be of long duration and if client is currently receiving services for the condition

If you selected "other" for disability type, please specify

NOTE: Chronic health condition - a diagnosed condition that is more than three months in duration and is either not curable or has residual effects that limit daily living and require adaptation in function or special assistance. Examples include but are not limited to: heart disease, severe asthma, diabetes, arthritis-related conditions, adult onset cognitive impairments (including traumatic brain injury, post-traumatic stress syndrome, dementia, and other cognitive related conditions), severe headache / migraine, cancer, chronic bronchitis, liver conditions, stroke or emphysema.

Household configuration

Single

Family with children

Family without children

Other

Are you head of household?

YES

How many children are in your household?

What is your total household size?

Please list information about all persons in your household. After entering information for each person hit ENTER.

Last & First Name, Birth date, Gender, and if they are they disabled or have special needs

Household members information:

HOUSING INFORMATION

Does the client

OWN

RENT

Other

Rent or mortgage payment amount

Payment frequency

Transportation

If this application is being made because of a fire or car accident, please answer the following questions:

Did you own or rent the property / vehicle that was damaged?

OWN

RENT

Were you at fault for the fire or accident?

YES

Were you insured?

YES

If you were insured, do you have a deductible?

YES

If you do have a deductible, what is the amount?

If you were insured, please estimate the percentage of your loss you expect to be covered?

All questions on the application must be answered before your application will be accepted. Applicants will be contacted via email to provide a statement which further explains their current hardship. All completed applications will be reviewed and voted on by the OCC Board of Directors. Majority vote rules. The Board of Directors' decision shall be final. The Board reserves the right to accept or reject any application, based on their sole judgement, for any reason that it deems appropriate. You will be notified if your application is approved or rejected. If approved, you will be asked to sign an OCC Partnership Agreement that will list the specific services OCC agrees to assist you with and the conditions you must abide by in order to receive services.

I have read and understand all of the information that has been provided for me. I also certify that all the information that I provided on this application is true and correct

Your Signature - Use your mouse to sign, or your finger (on mobile devices)

Date