MUM Client Intake Form

What type of assistance are you seeking?*

Select all that apply

Eviction Prevention

Utility Prevention

Prescription Drugs

Food Assistance

Your Contact Information

Please provide your basic contact information.

Name*

First Middle Last

Date of Birth

MM slash DD slash YYYY

Phone Number

Email Address

Ethnicity

Hispanic/Latino

Black/African American

Caucasion

Asian/Pacific Islander

Hawaiian

Native American

Other

Residence Status

Do you have a stable address or are you homeless?

I am homeless, no stable address

I am homeless, but I have a mailing address

I have a stable address/mailing address

Address

Street Address Address Line 2 City State ZIP Code

Type of Residence

What type of residence is the address for?

Stable/Permanent

Shelter

Transition/Temporary

Relative

Friend

Employment

Please tell us about your employment status

Are you presently employed?

Yes

Company Name

Enter the name pf the company your work for or enter "self-employed".

Company Phone

Enter company phone number.

Enter Your Salary

How much do you make? Enter the dollar amount.

Salary Schedule

Is this weekly, monthly or yearly?

Weekly

Monthly

Yearly

Other Income Sources

Please tell us about any other income you receive

Are you currently receiving unemployment benefits?

Yes

Enter your benefit amount

How much do you receive? Enter the dollar amount.

Child Support Income

List any income you receive from Child Support. Leave blank if none.

Spousal Support

List any income you receive from Spousal Support (i.e. Alimony, etc.) Leave blank if none.

Temporary Cash Assistance (TCA)

List any income you receive from TCA. Leave blank if none.

Food Stamps

List the amount of any Food Stamp benefits you receive. Leave blank if none.

Do you receive a pension? If yes how much per month?

Do you receive survivor benefits? If yes how much per month?

Do you receive SSI/SSDI? If yes how much per month?

Expenses

Tell us about your expenses

Do you pay Rent or Mortgage?

Select the option that matches your situation.

I pay rent

I have a mortgage

I do not pay rent or mortgage

How much do you pay in rent?

List your monthly rent payment amount.

How much is your mortgage?

List your monthly Mortgage Payment

Is this HOC or HUD related?

HOC

HUD

Neither

Do you pay child support?

Yes

Child Support Payment Amount

Enter the amount of Child support you pay each month

Do you pay for Child Care?

Yes

Child Care Payment Amount

Enter the total child care expenses you pay each month

List any Medical Expenses you pay

List any garnishments you have

Household Members

List the names and relationships of all household members.

Is one of your household members your spouse?

Yes

Is your spouse employed?

Yes

Enter your spouses income

How much does your spouse make? Enter the dollar amount.

Spouse Salary Schedule