Family Profile Form

Please complete the Family Profile form below:

Family Profile Form

First Name

Middle Name

Last Name

County

Street Address

Street Address Line 2 (Apartment #, Unit #, etc.)

City

State

Zip Code

Home Phone #

Work Phone #

Cell Phone #

Date of Birth (MM/DD/YYYY)

Gender *

Female

Male

Other

Race

Ethnicity - Hispanic? *

Yes

Marital Status *

Single

Married

Divorced

Legally Separated

Partner

Widowed

Housing *

Own

Rent

Section 8

Other

# of People Living in Home

Total Gross (Before Taxes) Family Income

Estimate of Debt Expenses (Monthly)

Monthly Income (check all that apply)

Alimony

Child Support

Job Earnings

Educational Assistance

Miscellaneous/Other

Pension/Retirement

Social Security

SSI

TANF

Unemployment

Veterans Benefits

Workers' Comp

Enter monthly income amount for each income source checked above

Characteristics

Head of Household (HOH)

HOH's Spouse

Agency Employee

Applicant

Disabled

No Health Insurance

Non-Custodial Parent

Veteran

Other

Family Type

Foster Parent (w/ foster children)

Grandparent (raising grandchildren)

Married or 2 Adults (w/ children)

Married or 2 Adults (no children)

Multiple (3+) Adults (w/ children)

Multiple (3+) Adults (no children)

Single Parent

Single Person (no children)

Other

Education (Highest Level Completed)

Master's Degree

Bachelor's Degree

Associate Degree

Some College Completed

Training Certificate

High School Graduate

GED

Some High School Completed

Other

I am interested in the following:

Lease Purchase Orientation

Homebuyer Education

Mortgage Delinquency Education

Rental-Readiness Education

Credit Education

Budget Education

Delinquent Mortgage Assistance

Delinquent Rent Assistance

Home Maintenance Assistance

Home Maintenance Education

Starting a Small Business

Expanding a Small Business

Other

Not Interested

I am interested in digital assistance with:

Using a Device

Home Internet

Obtaining a Device

Digital Skills

Other

Not Interested

I am interested in attending an outreach assistance event in my county.

Bibb County

Choctaw County

Dallas County

Fayette County

Greene County

Hale County

Lamar County

Perry County

Pickens County

Sumter County

Tuscaloosa County

Not Interested

I am interested in attending an outreach assistance event in my county.

Note: This event provides hands-on assistance with completing applications for Weatherization, Fortified Roof, Healthy Homes, and Delinquent Rental/Mortgage Assistance programs.

Thanks for submitting!

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Community Service Programs of West Alabama is a non-profit organization that works to empower low-income and vulnerable populations by providing resources and services that resolve immediate needs and lead to long-term self-sufficiency.

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601 Black Bears Way

Tuscaloosa, AL 35401

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