Bucks County Opportunity Council, Inc
Preliminary Application

Household Address / Phone Number: / Email Address
Household Members
Last Name, First Name / Relationship / Social Security Number / Date of Birth / Sex
M/F / Race / Health ins
(yes=x) / Last grade completed
1. / SELF / xxx-xx-
2. / xxx-xx-
3. / xxx-xx-
4. / xxx-xx-
5. / xxx-xx-
6. / xxx-xx-

*Race: 1 = African American, 2=Asian, 3= Pacific Islander , 4= Native American, 5=Caucasian, 6=Hispanic, 7=Bi-racial, 8-other

Income / Yes/No / Family Member / Monthly Amount
Employment
Unemployment Compensation
SSI or SSD
Retirement income from Social Security
Child Support
Alimony or spousal support
Veterans Disability
Pension from former job
TANF (cash welfare for families with children)
Food stamps
General Assistance (case welfare for adults)
Other:
Enter the number of adults receiving the following services:
How many adults in the household are currently employed: ______
How many adults in the household currently receive Mental Health services? ______
How many adults in the household currently receive Drug & Alcohol services? ______
How many adults in the household currently receive Domestic Violence services? ______
How many adults in the household are Veterans? ______
Has your household received Rental Assistance in the past 24 months? Yes ____ No ______
Do you currently have a Section 8 voucher? Yes ______No ______
Family Situation: Family is (check one) Homeless ______OR Near homeless ______/ BCOC Use Only:
4625
4621
4622
4623
4624
4626
4627

By signature on this application grants permission to Bucks County Opportunity Council, Inc. to verify any information concerning residence, employment, income, or energy supplier. I affirm that Bucks County is my legal residence. I swear/affirm that all information contained in this application is true, correct, and complete, to the best of my knowledge and belief.

Signature: ______Date: ______

How did you hear about BCOC? ______

Have you received services through BCOC in the past? Yes ______No ______

What BCOC programs are you interested in – please check all that apply:

Emergency Assistance –

  • Rental Assistance for families/individuals who are homeless or about to be homeless
  • Utility Assistance if utility is shut off or in jeopardy of being shut off

Economic Self-Sufficiency – case management for individuals who are motivated to gain livable wage job skills and be free of all government subsidies

Home Energy Conservation – weatherization services, for owners and renters, to reduce utility bills

Food Assistance – food pantries located throughout Bucks County

Senior Food Box – age 60 and over

Wheelz to Work – transportation assistance program

Free Tax Program – free income tax preparation

Other: Information and Referral

Are you working with any other agencies? Yes ______No ______

If yes, which ones: ______

Caseworker name: ______

Please tell us why you are applying for assistance: ______

Please answer all questions – thank you

Employment:

Are you employed? Yes______No ______

If yes, Employer name and address: ______

Job title: ______Rate of pay: ______Start date: ______

If no, name of last employer: ______

Job title: ______Dates of Employment: ______

Housing:

If you are homeless or seeking rental assistance, have you called the Bucks County Housing Link? Yes ___ No ____

Do you: Rent ______Own ______Doubled up with friends/family ______Homeless ______

Rent/mortgage amount: ______Do you live in Section 8/subsidized housing: Yes: _____ No: _____

If renter, landlord name, address, and phone #: ______

______

Type of home: Single ______Double ______Row ______Mobile Home ______Apartment ______

Is there mold visable in your home? Yes ____ No ____ Do you have cracks in your foundation? Yes ______No ______

Do you have a basement? Yes ____ No ____ Is it damp? Yes ____ No ____

Does the basement get wet when it rains? Yes____ No _____ If so, is there ever standing or running water in the

basement? Yes_____ No ____

Heating:

Electric ______Oil ______Gas ______Propane ______Other: ______

Utility company name: ______

Account Number: ______Age of heater: ______

Does the heater work: Yes ______No ______

Do you have a service contract: Yes ______No ______

Have you received LIHEAP in the past year: Yes ______No ______

Transportation:

Do you have a valid drivers license? Yes _____ No ______Do you own a vehicle? Yes ______No ______

If yes, year, make, and model: ______

Do you live near public transportation? Yes _____ No _____

Education:

Are you currently enrolled in an education or training program? Yes _____ No _____

If yes, name of program ______

Name of institution ______

Estimated completion date ______

Household Bills: please list monthly amounts

Rent/Mortgage ______Car Payments ______Cable ______

Electric ______Car Insurance ______Phones ______

Oil ______Gas ______Personal Items ______

Gas/Propane ______Bus/train ______Credit cards ______

Water/Sewer ______Child care ______Trash ______

Food ______Medical bills ______Prescriptions ______

Other ______

CONFIDENTIALITY WAIVER

I hereby give The Bucks County Opportunity Council, Inc. permission to release any information about myself, spouse, and/or my children to other agencies during the course of their work with me.

I hereby authorize other agencies to release information about me to The Bucks County Opportunity Council, Inc. as deemed necessary while seeking to help me.

I certify that the information provided is true to the best of my knowledge. I am aware that the information I have provided is subject to review and verification and I may have to provide documents to support this application. I am also aware that I am subject to immediate termination if I am found ineligible after enrollment and may be prosecuted for fraud and/or perjury. I allow release of this information for verification purposes and understand that it will be used to determine eligibility. (Federal Regulation 520CFR76-75-30)

Date: ______

Participant Signature: ______

Case Manager Signature: ______

Representative BCOC, Inc.