Pinellas County Urban League - Client Profile Form LIHEAP
Have you visited our offices before
Yes
No
First Name
MI
Last Name
Your Address
Street Address
City
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
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Hawaii
Idaho
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Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Zip Code
Are you a Public Housing Resident?
Yes
Telephone/Mobile
Email
What is the best way to reach out to you?
Phone Call
Text Message
Email Message
Healthcare Questionnaire
Do you currently have health insurance?
Yes
No
Are you interested in Marketplace insurance?
Yes
No
Demographics Information
Ethnicity/Race
Black or African-American
White
Hispanic/Latino
Native American
Asian
Native Hawaiian/Pacific Islander
Multicultural
Other
Gender
Male
Female
Transgender
Marital Status
Single (Not Married)
Married
Divorced
Widowed
Date of Birth
Last Four Digits of your Social Security #
Current Income:
What is your current total household income per month?
Are you a veteran?
Yes
No
Are you a person with a disability
Yes
No
Do you have a criminal history?
No Criminal Background
Misdemeanor
Felony
Employment Status: Are you employed or seeking work?
Self- Employed/ Contract work
Employed by an organization
Not employed, seeking work
Not employed, not seeking work
If you are employed, are you employed?
Full time
Part time
Temporary/Staffing
What is your current living/housing situation
Rent/Lease Home or Apartment
Own/Buying a Home
Staying with Friends/Family
Shelter
Homeless
Voter Information
Are you a registered voter?
Yes
No
Education Status
What is your highest level of education?
PhD
Master's Degree
Bachelor's Degree
Associates Degree
High School Diploma
GED
Did not complete High School
Vocation Training/Certifications
Tell us about your education (school, degree, coursework)
If you completed any vocational training, list it here
Benefits Information
Are you eligible and/or receiving any of the following? (select those that apply and enter the monthly amount
Unemployment
Food Stamps or Supplemental Nutrition Assistance Program (SNAP)
Temporary Assistance from Needy Families (TANF)
Supplemental Security Income (SSI)
State or Local Welfare (General Assistance)
Social Security Disability (SSDI)
Child Support
How much are you currently receiving in unemployment?
How much are you currently receiving in Food Stamps or SNAP?
How much are you currently receiving in TANF?
How much are you currently receiving in SSI?
How much are you currently receiving in State or Local Welfare?
How much are you currently receiving in SSDI?
How much are you currently receiving in Child Support?
In the past 60 days have you experienced any of the following?
Recently had a baby (natural, foster care, or adoption)
Recently married, divorced or separated
Recently moved
Recently released from incarceration
Recently lost health coverage
Recently homeless or in transitional housing
Household
List all of the genders and ages of dependent adults and children who live with you.
Gender
Male
Female
Transgender
Age
Contact Information