Financial Intake Form

General Info

Please provide us with basic information about yourself.

First name

Last name

Date of Birth

Month

Day

Year

Gender

Marital Status:

Ethnicity

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Is this a textable number?

Preferred method of contact

Emergency Contact Name

Emergency Contact Phone Number

Financial Requests

Would you like assistance with

Utility Bills

Rent or Mortgage

Financial Literacy (understanding of bills, statements, debt, budgeting, saving, investing...)

Other

Are you behind on rent/mortgage?

How many months are you behind on rent/mortgage?

Have you received an eviction notice?

What is the amount?

Are you behind on your utilities?

How many months are you behind on utilities?

Have you received a cutoff notice?

What is the amount?

Please describe in more detail what it is you need or how we can help:

How many people are over the age of 65?

How many adults are in the home (19 years - 64 years old)?

How many adolescence are in the home (12 years - 18 years old)?

How many school aged children are in the home (5 years - 11 years old)?

How many children under the age of 5 are in the home?

By signing, you confirm that the information is true and accurate. All financial and personal information provided will be kept confidential and protected in accordance with privacy laws and best practices. By submitting this form, you authorize Stored Goodness to use and share your information only as needed with referral services for the purpose of helping meet your specific needs. Your information will not be used or shared for any other purpose without your explicit consent.

Date and time

Month

Day

Year

Time

HoursMinutes

Signature

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Stored Goodness Info

How did you hear about Stored Goodness?

Have you used Stored Goodness before?

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Long answer

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