Winbush Enterprise Inc.

Name* This field is required.

First Name/Middle Initial

Last Name

Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Driver's License/ID Number* This field is required.

Last 4 of SSN* This field is required.

Phone* This field is required.

Area Code

Phone Number

Email* This field is required.

example@example.com

Communication Preference * This field is required.

Text/Email

Employment Status* This field is required.

Date of Birth* This field is required.

Date

Highest Level of Education* This field is required.

Gender* This field is required.

Male

Female

Prefer not to say

Other

Ethnicity* This field is required.

Hispanic

Non Hispanic

Race* This field is required.

American Indian or Alaskan Native

Asian

Black or African American

White

Hawaiian or Pacific Islander

Other

Veteran* This field is required.

Yes

Disability* This field is required.

Yes

If yes, please explain below

If yes was selecteted for Disability please explain

Benefit Info* This field is required.

N/A (the family does not receive any benefits)

Medicaid (Health/Medical Assistance)

Child Care (publicly funded child care)

Ohio Works First (cash assistance)

Supplemental Nutrition Assistance Program (food assistance)

Number of Prior Adult Felony Convictions

0-1

2-3

3-4

4 or more

Drug Use Caused Problems

Yes

Current Offenses Heroin/Opioid Related

Yes

Household Type* This field is required.

Single Adult

Widow / Widower

Single Parent (Female-Headed)

Single Parent (Male-Headed)

Married (NO Children)

Married (WITH Children)

Two Unrelated Adults

Other

Do you have dependents?* This field is required.

Yes

Dependent* This field is required.

First Name

Last Name

Date of Birth* This field is required.

Date

Relation to Applicant

Dependent

First Name

Last Name

Date of Birth

Date

Relation to Applicant

Additional Dependents

Please provide name, date of birth, and relation to applicant

How long have you lived at your current address?* This field is required.

Total Months

If less than 2 years, please provide prior address:

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Applicant's Income* This field is required.

Gross (i.e. before taxes)

Per* This field is required.

Week

Month

Year

Hours Worked per Week* This field is required.

Overtime* This field is required.

Yes

Job Title* This field is required.

Employer Name* This field is required.

Employer Phone* This field is required.

Area Code

Phone Number

Date Employment Began* This field is required.

Date

Total INCOME from all sources* This field is required.

Total Estimated Houshold/Utility Expenses

Please describe your housing goal(s)* This field is required.

When do you hope to reach your goal(s)?* This field is required.

Date

What barriers, if any, are preventing you from reaching your goal(s)?* This field is required.

What are you currently doing now to reach your goal(s)?* This field is required.

Applicant Signature* This field is required.

Clear

Date* This field is required.

Date

Participation in Winbush Enterprise Inc. (W.E.) is entirely voluntary and at your own risk. W.E. and its staff members shall not be held liable for any loss, damage, injury, or death that may result from participation in the program. You are responsible for ensuring that you are physically and mentally fit to participate in the program.

By signing this form, you acknowledge that you have read and understood the terms and conditions of participation in W.E. You agree to comply with all rules and regulations of the program and to release W.E. its staff members, and volunteers from any liability that may arise from your participation in the program.

Furthermore, you agree to indemnify and hold harmless W.E., its staff members, and volunteers from any claim, demand, or damage, including legal fees, arising from your participation in the program.

If you have any concerns or questions about the program or the terms of this disclaimer, please do not hesitate to contact W.E. staff members for clarification.

Applicant Signature* This field is required.

Clear

Date* This field is required.

Date

Terms and Conditions* This field is required.

Winbush Enterprise Inc.