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


Have you received any services from our agency before?