North Dallas Shared Ministries Application for Assistance

DIRECTIONS

Must live in NDSM's service area zip codes.
Must have a valid email address.
Must have a verifiable income.
Must complete all fields marked as * required.
Do not fill in your name under Other Adults or under Children. That area is for the additional people in your household.
Use dashes (-) for SS# (ex. 123-45-6789), phone# (ex. 214-358-8700) and when entering dates (ex. 04-04-2000)

New Client or Returning Client: * Select New Returning

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Applicant Information

First Name *    Middle Name    Last Name *

Address *    Apt#    City    Zip *

Social Security Number Format: 123-45-6789     Official Photo ID number *

Sex (M/F): * Select One Male Female      Date of Birth: (ex. 04-03-2000) *      Ethnicity: * Select One White Black Hispanic Asian Other

Telephone where you can be called: * Format: 123-456-7890     Type : * Select One Cell Home

Marital Status (married, divorced, single, widowed, etc.) : *     

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Household Information

Total people living in household: *

Where do you live - Apt/Condo, house, Duplex, Motel, Shelter, Trailer? *      DHA/Sec 8 : * Select One No Yes

Apt/Condo/Motel name *      Phone: * Format: 123-456-7890     Landlord:

Move-in Date: (ex. 04-03-2000) *

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List Information about ALL other Adults Age 18 or over living in your household:

Name First/Last                            Sex M/F     Date of Birth     Relationship to you     Social Security #Format: 123-45-6789
          
          
          
          

List Information about ALL children under 18 living in your household:
Name First/Last                            Sex M/F     Date of Birth     Relationship to you      Social Security #Format: 123-45-6789
          
          
          
          
          
          
          


      How many are on Medicaid?(use #'s)  *    How many are on SNAP(food stamps, use #'s)?  * 


HOUSEHOLD INCOME INFORMATION
Total HOUSEHOLD Monthly Income?  * $ 

Do not use $ signs when entering dollar amounts.

If you do not have a job then list your Other Income Source as Your Employer (example: Unemployment/SSI/SSDI).

Your Monthly Net Income:$  * $ 

Your Employer's Name: *  Phone:  *  Format: 123-456-7890

How long have you been employed?(example: 6 weeks, 7 months, years)  * 

  


Do not complete Other Monthly Income unless you have more than 1 monthly income source.


Do not use $ signs when entering dollar amounts.



Other Monthly Income? $ 

Select One
Employment 
  Unemployment Compensation
  SS Retirement
  SSI
Child Tax Credit
SSDI
Workers Compensation
Pension
TANF
  Other



Other Monthly Income?  $ 

Select One 
Employment 
  Unemployment Compensation
  SS Retirement
  SSI
Child Tax Credit
SSDI
Workers Compensation
Pension
TANF
  Other



  Other's employer is used for Spouse/Roommate/Additional Resident's Income Information.


Monthly Income? $ 

Other's employer: Phone: Format: 123-456-7890 

How long have you been employed?(example: 6 weeks, 7 months, years)

Email Address:  *

Enter Email Address Again:  *

FINANCIAL ASSISTANCE NEEDED
What kind of help do you need?  *


Why do you need this help?  *


 A RESPONSE WILL BE EMAILED TO YOU WITHIN 12 HOURS ONCE YOU CLICK SUBMIT.

  PLEASE READ SCREEN AFTER YOU CLICK SUBMIT FOR IMPORTANT DIRECTIONS.

   
                                                       
                                                                                                                           Updated 2.26.2023.