Client Intake

Client Application for Assistance (English)

Step 1 of 13

Release Information

Please read and check all.(Required)

I understand that the mission of NeighborUp is to support families and individuals in crisis. This emergency assistance is not intended to be an income supplement or to be provided on a regular basis.

Consent Item 2(Required)

By signing this form, I give NeighborUp permission to contact whomever necessary to verify my need, make a responsible decision regarding assistance to my household, and to seek further resources with regard to my request.(Required)

Consent Item 3(Required)

This permission includes but is not limited to, property managers, mortgage companies, utility or other service providers, medical providers and pharmacies.(Required)

Consent Item 4(Required)

I understand that I will be asked to provide documentation of my income, expenses, and financial crisis.(Required)

Consent Item 5(Required)

I also understand the information I provide will be used to verify my need, negotiate on my behalf, and to assist my household or other agencies assisting my household.(Required)

Consent Item 6(Required)

My agreement indicates that all information I have given NeighborUp is accurate and complete to the best of my knowledge.(Required)

Consent Item 7(Required)

I understand that if I have given false information, my household and I will be barred from receiving any future assistance from NeighborUp. Also, the incident may be shared with other organizations.(Required)

Applicant Information

First Name(Required)

Last Name(Required)

Preferred Name

Preferred Language(Required)

English

Spanish

Other

Other Language(Required)

Are you or is anyone in your household a U.S. Military veteran?(Required)

Yes

Where do you live now?(Required)

Cary or Morrisville

Apex, Holly Springs, Fuquay Varina, Willow Spring, New Hill, or Friendship

Cary, in an Oxford House

Other city, at my permanent address

At a temporary location (hotel, friend's house, or other) in Cary or Morrisville

I slept outside or in my car or other place not meant for human habitation.

Do you have a child enrolled in a public K-12 school in any of the following cities? Cary, Morrisville, Apex, Holly Springs, Fuquay Varina, New Hill, Willow Spring, Friendship

Yes

Was your last permanent address in Cary, Apex, Holly Springs, Fuquay Varina, Willow Spring, New Hill, or Friendship?(Required)

Yes

Referral letter from your Peer Advocate(Required)

I understand that the Peer Advocate must provide a referral letter, in addition to this application.

Identifying Information

Your Street Address(Required)

Street Address Address Line 2

City(Required)

Zip Code(Required)

Enter Your City(Required)

Phone(Required)

Email(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Race and Ethnicity(Required)

Employment Type(Required)

Current Employer(Required)

Household Information - Other Adults

Are there other adults in your household?(Required)

Yes

Add All Household Adults

First Name	Last Name	Date of Birth	Gender	Race and Ethnicty	Employment Type	Current Employer	Actions

There are no Adults.

Maximum number of adults reached.

Household Information - Children

Do you have children (under 18 years of age) living with you?(Required)

Yes

Add All Household Children

First Name	Last Name	Date of Birth	Gender	Race and Ethnicty	Child's School	Actions

There are no Children.

Maximum number of children reached.

Household Information - Income

Household Income Sources(Required)

Paycheck

Disability

Social Security

Self-employment

Financial Aid

Child Support

Cash

Gig work

Small business

Pension

Other

Normal monthly income (average from all sources, before taxes or deductions).(Required)