WATERBURY DEVELOPMENT CORPORATION

CD Year 41

10/1/2015 – 9/30/2016

ESG - CLIENT INTAKE DATA FORM

The following statistical information is required by the United States Department of Housing and Urban Development (HUD). It is required that every social service agency that receives Emergency Solutions Grant (ESG) funds fill out a monthly Direct Benefit Activities report. This information will be used to process our annual Grantee Performance Report. The information provided on this form is pertinent for future funding of this program. If this program is for persons under the age of eighteen, this questionnaire must be filled out by parent or legal guardian. THIS INFORMATION IS STRICTLY CONFIDENTIAL.

Client: ______Signature: ______Date: ______

Program Name: ______

1. Have you used this program, or completed an Intake Form, sinceOctober 1st of the current year?Yes: _____ No: _____

(If you answered yes, please do not complete the rest of this questionnaire).

2a. Marital Status: Single: ______Married: ______Divorced: ______Widowed: _____

2b.Gender: Male_____ Female______Transgender______Unknown______

2c.Senior 62 years or older: Yes_____ No_____

3.Please circle the total number of people in your family and circle your total annual income under the family column.

* / 1 person family / 2 person family / 3 person family / 4 person family / 5 person family / 6 person family / 7 person family / 8 person family
A / $0 - $17,050 / $0 - $19,500 / $0 - $21,950 / $0 - $24,350 / $0 - $28,410 / $0 -$32,570 / $0 - $36,730 / $0 - $40,890
B / $17,051- 28,400 / $19,501 - 32,450 / $21,951- 36,500 / $24,351- 40,550 / $28,411- 43,800 / $32,571- 47,050 / $36,731- 50,300 / $40,891- 53,550

C

/ $28,401- 45,450 / $32,451 - 51,950 / $36,501- 58,450 / $40,551- 64,900 / $43,801- 70,100 / $47,051- 75,300 / $50,301- 80,500 / $53,551- 85,700

D

/ $45,451 & UP / $51,951 & UP / $58,451 & UP / $64,901 & UP / $70,101 & UP / $75,301 & UP / $80,501 & UP / $85,701 & UP

*The above letters represent income limits based on percentages of Waterbury’s median income:

A=Extremely Low (30%) B=Low (50%) C=Moderate (80%) D=Non Low Income (+80%)

4.ARE YOU CURRENTLY HOMELESS:YES______NO______

5.PLEASE CHECK ANY OF THE FOLLOWING THAT APPLY TO YOU:

Chronically Homeless: ____Severely Mentally Ill: ____ Chronic Substance Abuse: ____ Other Disability: ____

Veteran: ______Person with HIV/AIDS: ______Victim of Domestic Violence: ______

6.ETHNICITY

ARE YOU OF LATINO/HISPANIC DESCENT? YES: _____ NO: _____

THE TWO ETHNIC CATEGORIES ARE DEFINED AS FOLLOWS:

Definitions for City of Waterbury intake form revised by the Office of Management and Budget (OMB)

a)Hispanic or Latino – a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term, “Spanish origin,” can be used in addition to “Hispanic or Latino.”

b)Not Hispanic or Latino – a person not of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

7.RACE

PLEASE CHECK ONE OF THE FOLLOWING CATEGORIES REGARDING YOUR RACE:

White: _____ Black/African American: ______Asian: ______American Indian/Alaskan Native: _____

Native Hawaiian/ Other Pacific Islander: ______American Indian/Alaskan Native & White: _____ Asian & White: _____

Black/African American & White:_____ American Indian/Alaskan Native & Black/African American: _____Other (Multi-Racial): _____

THE FIVE RACIAL CATEGORIES ARE DEFINED AS FOLLOWS:

Definitions for City of Waterbury intake form revised by the Office of Management and Budget (OMB)

a)American Indian or Alaskan Native – a person having origins in any of the original peoples of North and South America (including Central America), andwho maintains tribal affiliation or community attachment.

b)Asian – a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

c)Black or African American – a person having origins in any of the black racial groups of Africa. Terms such as “Haitian” or “Negro” can be used in addition to “Black or African American.”

d)Native Hawaiian or Other Pacific Islander – a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

e)White – a person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

8.Physical Disability Please select: Yes____ No_____

Effective: March 6, 2015