Albemarle Area United Way
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Community Care Collaborative Funds are only available for residents of Pasquotank, Camden or Perquimans County.
Please complete all information in order to better assist you.
Phone Type
Mobile/Cell
Home/Landline
Work
Gender
Female
Male
Other/Prefer not to say
Race/Ethnicity
White/Caucasian
Black/African American
Native American
Asian
Mixed Race
Family Status
Single
Married
Separated
Divorced
Widowed
Other Persons Living with you (include name, date of birth, and relationship)
Please check fo all assistance received
Disability SSI
Handicap Aids
Mobility
Learning Impairment
Speech Impairment
Visual Impairment
None of the Above
Have you worked with any of the following Social Services
Camden County Social Services
Pasquotank County Social Services
Perquimans Social Services
Health Department
I havve not worked with any of the above agencies
Check all agencies you receive assistance from
Medicaid
NC Health Choice
Work First Family Assistance
Food Stamps
Section 8 Housing
EIC
WIC
SSI/Disability
None of the Above
How much do you receive in Food Stamps per month
How much do you receive in SSI/Disability
What kind of assistance do you need and the reason?
What have you done to address this issue?
What agencies have you contacted and when?
Why is this request considered a temporary gap servie and what be different next month?
Who referred you or how did you find out about this program?
Employment Status
Full Time
Part Time
Temporary
Seasonal
Unemployed
Please list all employers, name, address, phone number
If unemployed, when were you last employed?
Mortgage/Rent Amount
Car/Transportation Expenses
Power/Gas/Water Expenses
Food Expenses
Other Expenses (Cell, cable, etc)
Please provide your income amount and indicate if that is weekly, biweekly or monthly. If you receive disability please indicate that
Hae you received assistance from other agencies in the last 6 months for the same request?
Yes
No
If yes, please give the agency
Submit
Thanks for submitting!