Survey - STAR Outreach - Star of Hope Mission

STAR Outreach

Name of Person Making Request:

Field Is Required First

Middle

Field Is Required Last

Suffix

Field Is Required Date of Birth:

Street 1:

City/Town:

State / Province:

ZIP / Postal Code:

Field Is Required Email:

Field Is Required Phone Number:

If you respond and have not already registered, you will receive periodic updates and communications from Star of Hope Mission.

Field Is Required Social Security Number: (last four digits)

Field Is Required Marital Status:

Field Is Required Number of Children:

Field Is Required Social Service Request: Please make between 1 and 5 selections from the choices below.

Star of Hope will be unable to assist anyone with rental payments or arrears to anyone who is in the process of eviction (landlord filed; court date set; or court mandated eviction).

If in need of rental/hotel assistance, how much is your current rent?

How much are you requesting for rental assistance?

How much are you requesting for hotel assistance?

How much do you have to contribute to your rent or hotel?

Field Is Required Are you receiving support from any other agency for rental/hotel assistance?

If yes, how much?

Field Is Required Are you currently employed?

If no, how long have you been unemployed?

Why were you terminated from your previous employer?

Field Is Required Have you been employed on your CURRENT job for 6 months or more?

Field Is Required b. Do you receive any other source of income? If yes, what is the source? If no, click "Other" and write "N/A". (Select one of the available choices or enter a different value.) b. Do you receive any other source of income? If yes, what is the source? If no, click "Other" and write "N/A". Click this to indicate that you will select an existing value. Tab to next input." b. Do you receive any other source of income? If yes, what is the source? If no, click "Other" and write "N/A". b. Do you receive any other source of income? If yes, what is the source? If no, click "Other" and write "N/A". Click this to indicate that you will enter a new value. Tab to next input." b. Do you receive any other source of income? If yes, what is the source? If no, click "Other" and write "N/A". Provide your answer here

If you selected other as your source of income, please explain the type of income you are receiving.

Field Is Required How much is your current monthly income? (enter $0, if not applicable)

Field Is Required Have you received Financial Assistance for this same issue from Star of Hope or any other agency in the last 12 months?

Field Is Required Race:

Field Is Required Ethnicity:

Field Is Required Gender:

Field Is Required Disabling Condition:

Military Status: (Select one of the available choices or enter a different value.) Military Status: Click this to indicate that you will select an existing value. Tab to next input." Military Status: Military Status: Click this to indicate that you will enter a new value. Tab to next input." Military Status: Provide your answer here

Field Is Required Please provide a statement explaining your reason for this request.

Field Is Required Were you referred by an agency? If yes, what agency? If no, write "NO" below.

Are you able to provide the following documents? Please make between 1 and 3 selections from the choices below.

2 Current Paycheck Statements or a Copy of your Benefits Statement
Driver's License or State I.D.
Provide Documentation from Apartment Complex or Landlord

Field Is Required Are you available for an in-person or virtual interview? For Virtual Interview Phone Type:

Field Is Required b. Do you have access to the app Microsoft TEAMS?

Field Is Required c. Do you have access to the app Zoom?

A representative from the Outreach Department will review your submission.