Assistance.

Thank you for requesting assistance from Titus County Cares.

In an effort to assist in a timely manner, please complete the following form in its entirety and truthfully.

You should receive a response typically within three (3) business days.

Name:* (First and Last)

Gender:*
Male
Female

Date of Birth:*

Email Address: *

Primary Phone:

Secondary Phone:

Marital Status: *
Single
Married
Divorced
Widowed

Street Address:

City:     State:    Zip:

PEOPLE WHO LIVE WITH YOU:

Member #1 Name: (First and Last)

Age:

Is this member of your household employed?
Yes
No

Member #2 Name: (First and Last)

Age:

Is this member of your household employed?
Yes
No

Member #3 Name: (First and Last)

Age:

Is this member of your household employed?
Yes
No

Member #4 Name: (First and Last)

Age:

Is this member of your household employed?
Yes
No

NEAREST RELATIVE:

(WHO DOES NOT LIVE WITH YOU)

Name: (First and Last)

Relative's Phone:

EXPENSES:

How much do you pay a month for the following?

Rent/Mortgage:

Home/Renters Insurance:

Gas/Propane:

Water:

Electricity:

Auto:

Auto Insurance:

ASSISTANCE:

How were you referred to Titus County Cares?

Church Affiliation:

Do You Need Food Assistance? *
Yes
No

Do You Need Additional Food for Your Family? *
Yes
No

Do You Need a Mammogram? *
Yes
No

Are You OR a Member of Your Household a Victim of Sexual Assault? *
Yes
No

Why do you need assistance? *