CDBG Client Intake Form

Hidden IDs

Enrollment ID

Contact ID

Client Information

Agency

Project

Date

Child First Name

Child Last Name

Street Address

City

State

Ethnicity

HispanicNon-Hispanic

Client Age

Sex of Head of Household

FemaleMale

Age of Head of Household

Number of People in Household:

Name of Title I School

Enter the name of your child's school to check if it is a Title I school.

Does your child attend a Title I school from the list above?

YesNo

Receives free/reduced lunch

Client Race

Use CTRL when choosing to select multiple

Household Annual Income:

Proof of Income (example: pay stub, W-2, tax return, unemployment benefits, etc.)

Proof of Address (example: bank statement, Drivers License/ ID Card, Insurance card, lease agreement, etc.)

I certify that all information on this form is true and correct and that all income is reported. I understand this information is being given for the receipt of federal funds, that the information on this application may be verified, and that deliberate misrepresentation of the information may subject me to prosecution under applicable state and federal laws.

I agree

Date

For Big Brothers Big Sisters Staff Only

Presumed Income Category

Staff Signature

Date

Contact Information