RICKY'S LIFELINE CLIENTS
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Universal Assistance Intake Form
We Are Here To Service You!
Zip code
1. Select All Assistance Needed
Select All Services You Need
Housing Assistance
Food Assistance
Phone Service
Internet Service
Utility Assistance
Medical/Health Assistance
Health & Fitness
Employment Assistance
Education Or Training
Clothing Assistance
Funeral Plans & Services
Drug or Alcohol Assistance
Domestic Issues
Legal Services
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2. Select All Qualifying Benefits You Have
Select all benefits you have
Medicaid
Foodstamps
SSI (Supplemental Income)
SSDI (disability) run under INCOME.
SSA or (Retirement) run under INCOME
Housing (HUD, Section8, Voucher)
Income: W2 or Tax Return
Veteran's Survivor Benefits
Medicare(Red, White & Blue Card) Not for Lifeline
None yet. Applying for benefits soon
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3. First and Last Name
*
4. Date of birth: (Tip: Tap on the year 1st)
*
5. Social Security Number
6. Full Address( Include Apt #, City, State, Zip)
7. Contact Number To Reach You:
8. Email:
9. How did you hear about us?
Document Page
If you have any of these documents available please enter them here, otherwise skip this section.
W2, Tax Return, Award Letter (Foodstamps, Medicaid, SSI, Disability, Social Security(Retirement), Utility Bill
Award Letter or Utility Bill
State ID or Driver's License
State ID
Birth Certificate(Optional)
Birth Certificate
Social Security Card(Optional)
Social Security Card
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