Assistance Application | Interfaith Community Outreach

General Information

Name*

First MI Last

Birth Date*

Identification Type*

(e.g. Drivers License Number, etc.)

Identification Number*

ID State*

Home Phone

Cell Phone*

We need a contact phone number so if you have only one please fill this one out.

Other Phone

Email Address*

Race*

American Indian
Asian
Black
Latino
Pacific Islander
White/Caucasian
Other

Mailing Address*

Street Address Address Line 2 City State ZIP Code

County*

Physical Address*

Street Address Address Line 2 City State ZIP Code

County*

Past Mailing Address

Street Address Address Line 2 City State ZIP Code

County

Family Status

Marital Status*

Single
Married
Divorced
Separated
Widowed

Spouse Name

First Last

Spouse Birth Date

Other person(s) living with you:

Other Person 1 Name

First Last

Relationship

Age

Birth Date

School

Other Person 2 Name

First Last

Relationship

Age

Birth Date

School

Other Person 3 Name

First Last

Relationship

Age

Birth Date

School

Other Person 4 Name

First Last

Relationship

Age

Birth Date

School

Special Needs

Disabilities / Impairments*

Type of assistance you need today and reason?*

What have you done to address these issues?*

What other agencies have you contacted? When?*

Why is this request considered a temporary gap? What will be different next month?*

Who referred you? How did you hear about us?*

Social Service Assistance

Currituck Social Services
Dare County Social Services
Health Department

Do you receive help from any of the following programs?

Medicaid
NCHC
WFFA
Food Stamps
Section 8 Housing
WIC
SSI / Disability
EIC
Other

Name of DSS Caseworker

First Last

Phone of DSS Caseworker

Household Income and Expenses

Person 1 Income

Name*

First Last

Weekly $*

Bi-Weekly $*

Monthly $*

Other $

Present Employer*

Supervisor

Employer Address

Employer Phone

Profession Type

Employment Type

Full Time
Part Time
Temporary
Seasonal

Past Employer*

Past Supervisor

Past Employer Address

Past Employer Phone

Last Date Worked

Person 2 Income

Name*

First Last

Weekly $*

Bi-Weekly $*

Monthly $*

Other $

Present Employer*

Supervisor

Employer Address

Employer Phone

Profession Type

Employment Type

Full Time
Part Time
Temporary
Seasonal

Past Employer*

Past Supervisor

Past Employer Address

Past Employer Phone

Last Date Worked

Name of Bank*

Checking Balance*

Savings Balance*

Expenses

Mortgage/Rent*

Car/Transportation*

Utilities*

Cell Phone*

Cable*

Food*

Total Other*

List "Other" Expenses

Are you a member of a local church?*

Yes
No

Are you a Veteran?*

Yes
No

Have you applied to the ICO for assistance in the past?*

Yes
No

Document Upload

You can take a picture of your documents or id and upload them below.

Picture ID Files - Drivers License*

You can upload multiple images or files

Drop files here or

Max. file size: 9 GB.

Copies of Bills*

You can upload multiple images or files

Drop files here or

Max. file size: 9 GB.

Agreement & Signature

I certify that the information on this form is true and correct. Falsified information will result in denial of assistance. I give Interfaith Community Outreach (ICO) permission to verify any information necessary to determine my eligibility for Emergency Assistance. I authorize ICO to discuss my household’s situation with members of Dare and Currituck County DSS, Food Pantry, Hotline, Health Department and any other individuals or organizations necessary to determine the need and identify appropriate assistance. I understand that there are regulations protecting the confidentiality of authorized information to verify assistance received or denied. I hereby acknowledge that this consent is truly voluntary and is valid for 180 days. I understand that I may revoke this consent at any time except to the extent that information has already been released before I revoke it.

Signature*

Date*

Phone

This field is for validation purposes and should be left unchanged.

General Information

Family Status

Other person(s) living with you:

Special Needs

Social Service Assistance

Household Income and Expenses

Person 1 Income

Person 2 Income

Expenses

Document Upload

Agreement & Signature

Hours

Pages

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