Intake | Application
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By submitting this form, I certify that the information I have provided is complete and correct to the best of my knowledge and is made in good faith. I further give my consent to Community Action Alger-Marquette personnel to verify eligibility and provision of services. I am aware that this application may be forwarded to other departments of Community Action Alger-Marquette. I understand that this information will be used to determine eligibility for any and all services provided to me by Community Action Alger-Marquette. I further understand that this information may be disclosed to other service providers in order to determine my eligibility for their services. This information will be shared on a need-to-know basis only.

Services you are applying for:

Please provide a brief description of your situation and what services you are seeking:

Please enter information for each occupant on a separate line using the following format: Full Name, Date of Birth, Sex (M or F), Race, Hispanic (Y or N), Disabled (Y or N), Education Level, Type of Health Insurance, Relationship to Head of Household

City/State/ZIP/County

If different from Mailing

Marital Status
Family Type
Do you receive food stamps?
Do you receive WIC Benefits?
Do you have childcare?
Health Insurance:
Medication:
Do you have transportation?
Do you have special needs children?
Have you received any services from our agency before?
Have you received services from another agency?
Home Ownership:
Home Type
Home Structure
Location
Heating Fuel Type:

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