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4
25%
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Name:
(Required)
First
Last
SSN:
ie: 012 – 34 – 5678
Date of Birth:
(Required)
MM slash DD slash YYYY
Pronouns:
ie: She/her, He/Him, They/Them, She/He, She/They, He/They, Xe/Xem, It/Its, Other
Gender:
Female
Male
Transgender
Other
Unknown/Not Reported
Nonbinary
Questioning
Preferred way to be contacted:
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Home Phone
Mailing Address
Cell Phone
Email
Home Phone #:
(Required)
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
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Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
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Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
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Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
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Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
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Holy See
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Hungary
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India
Indonesia
Iran
Iraq
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Isle of Man
Israel
Italy
Jamaica
Japan
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Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
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Malawi
Malaysia
Maldives
Mali
Malta
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Myanmar
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Nigeria
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Panama
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Portugal
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Saint Kitts and Nevis
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Samoa
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Senegal
Serbia
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Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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Email:
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Brief Description of Need:
Consent
(Required)
Yes, I consent
I consent to give Action Inc. staff permission to share my personal information internally within Action Inc. to its programs, and to report my personal information to the entities that fund, audit, or evaluate Action Inc. programs as may be required. I understand that Action Inc. will maintain the confidentiality of personal and financial information I provide about myself and my family members receiving services from Action Inc., except that Action Inc. may share that information within Action Inc. as necessary to provide services to me and to administer its other programs. Action Inc. may disclose information as required by or upon request of government agencies and other entities that fund, regulate, audit, monitor or investigate Action Inc., and as authorized or required by law, legal process, or court order. For any other purpose, Action Inc. will only disclose information with my written consent.
DEMOGRAPHIC INFORMATION
Primary Language:
Secondary Language:
Translator Needed:
Yes
No
Maritual Status:
Single
Married
Divorced
Separated
Widowed
Unmarried Partners
Unknown
Citizenship Status:
Documented Non-Citizen
Student/Visitor Visa
Undocumented Non-Citizen
US Citizen
Unknown
Disabled:
Yes
No
Disconnected Youth: (age 14-24 years old who are not working nor in school)
Yes
No
Ethnicity:
Hispanic/Latino
Not Hispanic/Latino
Unknown/Not Reported
Race:
American Indian/Alaskan Native
Native Hawaiian/Other Pacific Islander
Asian
White
Black/African American
Multiracial/Biracial
Other
Unknown/Not Reported
Education Level:
Pre-K (ages 0-5)
Grade K-8
Grades 9-12. non-graduate
High School Graduate
GED/Equivalency Diploma
Some Post-Secondary Education, no degree
College Graduate (2 or 4 years)
Graduate School/Degree
Trade/Vocational Certificate
Other
Unknown/Not Reported
Military Status:
Veteran
Never served in the military
Active Military
Unknown/Not Reported
Employment Type:
Employed Full Time
Employed Part Time
Migrant/Seasonal Farm Worker
Retired
Seasonal Employment
Unemployed Student
Unemployed (not in labor force)
Unemployed (short-term, less than 6 months)
Unemployed (long-term, more than 6 months)
Unknown/Not Reported
Pregnant:
Yes
No
If yes, due date:
How did you hear about Action Inc.?:
HOUSEHOLD INFORMATION
Family Type:
Single Person
Single Parent (Female)
Single Parent (Male)
Two-Parent Household
Two Adults, No Children
Non-related adults w/ children
Multigenerational Household
Other
Unknown/Not Reported
Location Type:
(Required)
Own
Rent without subsidy
Rent – with subsidy or in public housing
Doubled Up (couch surfing, etc.)
Homeless – not in shelter
Shelter
Other
Living Arrangement:
Place not meant for human habitation
Transitional/Temporary Housing
Residential Program/Facility
Other Permanent Housing
Other
Unknown/Not Reported
Housing Type:
Apartment
Multi-family Home
Single-family Home
Mobile Home
Condo/Townhouse
Other
Heating Type:
Electric
Oil
Natural Gas
Kerosene
Propane
Wood/Coal
Other
None
Unknown
Is Heat Included in Rent?:
Yes
No
INCOME
No Income:
(Required)
Yes
No
Income Type:
Amount & Frequency:
Income Type:
Amount & Frequency:
Income Type:
Amount & Frequency:
Income Type:
Amount & Frequency:
ASSETS
Asset Type:
Value:
Asset Type:
Value:
Asset Type:
Value:
BENEFITS
Benefits Received:
(Required)
Affordable Care Act Subsidy
Chapter 115 Veterans’ Benefits
Childcare Voucher
EAEDC
Fuel Assistance (LIHEAP)
HomeBASE
HUD-VASH
Public Housing (NOT Section 8)
Section 8/Housing Choice Voucher
QUEST Voucher
SNAP
SSDI
SSI
State Supplement
TAFDC
WIC
Other Permanent Supportive Housing
None
(select all that apply)
Expenses
Household Expense:
Amount & Frequency
Household Expense:
Amount & Frequency
Household Expense:
Amount & Frequency
Household Expense:
Amount & Frequency
Health Insurance:
Yes
No
Insurance Type:
CHIP
Employment Based
Medicare
Private Health Insurance/Direct Pay
ConnectorCare
Medicaid/MassHealth
VA/Military Health Care
Other
Unknown
HOUSEHOLD MEMBERS
Number in Household***:
(Required)
1
2
3
4
5
6
7
Head of Household (HoH) Name:
(Required)
Full Name:
Date of Birth:
MM slash DD slash YYYY
Gender:
Full Name:
Date of Birth:
MM slash DD slash YYYY
Gender:
Full Name:
Date of Birth:
MM slash DD slash YYYY
Gender:
Full Name:
Date of Birth:
MM slash DD slash YYYY
Gender:
Full Name:
Date of Birth:
MM slash DD slash YYYY
Gender:
Full Name:
Date of Birth:
MM slash DD slash YYYY
Gender:
Full Name:
Date of Birth:
MM slash DD slash YYYY
Gender: