Benefit Screening Form

EMPL ID

Full Name(Required)

Address(Required)

Street Address City State ZIP Code

Email(Required)

Phone(Required)

Date of Birth(Required)

Marital Status(Required)

Country of Birth(Required)

Citizenship Status(Required)

Primary Language Spoken

Ethnicity(Required)

Other Ethicity(Required)

Are you a U.S. Veteran?(Required)

Education Status(Required)

Major:

Employment Status:(Required)

Housing(Required)

Household Size:(Required)

Dependents under age 19:

Service Request (Please select all interested services)

Public Benefits (SNAP, CASH Assistance, etc.)

Legal Assistance

Healthcare

Tax Preparation

Other

Other Interested Service (explain)

This field is for validation purposes and should be left unchanged.