APPLICATION FOR EMERGENCY ASSISTANCE WFNJ/EA-1A (New 7/06)

Emergency Assistance (EA) is provided to WFNJ/TANF/ GA and Supplemental Security Income (SSI) recipients on a as needed basis. Assistance includes emergency allowance for food, clothing, furniture, utility, storage, shelter placement, security deposit and or back rent. Temporary rental assistance may be authorized in order to resolve imminent or actual homelessness.

Applicant Information

Date of Application * +

Emergency Assitance

TANF Case #

GA Case #

SSI

Applicant Information

First Name *

Last Name *

Birth Date * +

Gender: *

Male

Female

Social Security Number *

Race (For HMIS) *

Hispanic/Latino *

Yes

Address *

Phone Number *

Last Permenant Address *

When did you last live there? (Month and Year): *

Please check all that apply to this emergency:

I am homeless

I am about to be homeless/I need to leave where I have been staying

Applicant Explanation of Emergency
EXPLAIN SITUATION FULLY (if homeless, please include what efforts have been made to find new housing):

my permanent home	a place I have been staying with other people	a shelter	a transitional housing program
a rehabilitation center	a hospital	a prison a jail	other (PLEASE EXPLAIN) other (PLEASE EXPLAIN)

I need to move and cannot pay security	I need to move and cannot pay a utility deposit	I have a shut-off notice for utilities and I cannot pay my bill	My utilities are off now
My utilities will be turned off this week	I owe less than 3 months rent or mortgage	I owe more than 3 months rent or mortgage	I have no food
I live in a situation where I cannot afford my housing costs on a regular basis	I need help buying furniture	Other