RICKY'S LIFELINE CLIENTS

Universal Assistance Intake Form

We Are Here To Service You!

Zip code

1. Select All Assistance Needed

2. Select All Qualifying Benefits You Have

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

W2, Tax Return, Award Letter (Foodstamps, Medicaid, SSI, Disability, Social Security(Retirement), Utility Bill

Award Letter or Utility Bill