Client Assistance Program

CLIENT ASSISTANCE PROGRAM ELIGIBILITY FORM

Eligibility for this program is based on financial need.
Proof of income is required to qualify for the Client Assistance Program (CAP). Along with this application, you will need to submit a statement of earned income, which may be obtained from the Federal Building on 12th Street. As an alternative, you may submit your most recent income tax return or your two most recent pay stubs. The information must be updated every six months and anytime your income, household size, and/or medical insurance status changes. Whether or not a discount has been applied to your fee(s), you are responsible for the full payment of your bill.
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number

List your name and the name(s) of all individuals who live with you and contribute to or are supported by the household income*

	Name	Relationship	Age	Sex	Employer	Income
Yourself
Individual 2
Individual 3
Individual 4

Are you currently employed?*

YesNo
If yes, list where you are employed:
Do you work seasonally?*

YesNo
If yes, list where you work seasonally:
How much money do you bring in per month?*
How much money do you bring in annually?*
Are you homeless?*

YesNo
If you are not working, how are you meeting your monthly expenses?
Do you currently have health insurance*

YesNo
If yes, please provide the following insurance information:
Primary Insurance:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
ID #:
Group #:
Category of Earnings

List all earnings and benefits that you are receiving in your household
Are you receiving wages, salary, or tips before deductions?*

YesNo
If yes, list the amount per month/year:
Are you receiving unemployment compensation?*

YesNo
If yes, list the amount per month/year:
Are you receiving worker’s compensation benefits?*

YesNo
If yes, list the amount per month/year:
Are you receiving social security benefits?*

YesNo
If yes, list the amount per month/year:
Are you receiving supplemental security income?*

YesNo
If yes, list the amount per month/year:
Are you receiving Public Assistance/Alaska Temporary Assistance Program/ ATAP Cash Assistance?*

YesNo
If yes, list the amount per month/year:
Are you receiving Veteran’s Benefits?*

YesNo
If yes, list the amount per month/year:
Are you receiving Military Subsidies (BAH, BAS, COLA)?*

YesNo
If yes, list the amount per month/year:
Are you receiving survivor benefits?*

YesNo
If yes, list the amount per month/year:
Are you receiving pension or retirement Income?*

YesNo
If yes, list the amount per month/year:
Are you receiving interest?*

YesNo
If yes, list the amount per month/year:
Are you receiving Permanent Fund Dividend (PFD) from State of Alaska?*

YesNo
If yes, list the amount per month/year:
Are you receiving Dividends (not including Alaska PFD)*

YesNo
If yes, list the amount per month/year:
Are you receiving rents, royalties, estates and trusts?*

YesNo
If yes, list the amount per month/year:
Are you receiving educational assistance for general living expenses (grants & scholarships)?*

YesNo
If yes, list the amount per month/year:
Are you receiving alimony?*

YesNo
If yes, list the amount per month/year:
Are you receiving financial assistance from outside the household (foster care, etc.)?*

YesNo
If yes, list the amount per month/year:
Are you receiving strike benefits?*

YesNo
If yes, list the amount per month/year:
Are you receiving any other income?*

YesNo
If yes, list the amount per month/year:
TOTAL INCOME
Please list two references who are not living with you:
Reference 1

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Years Known
Reference 2

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Years Known
I authorize Continuing Hope Counseling LLC to verify information provided on this application. I also authorize all government agencies, employers, financial institutions and any companies, agencies or persons listed herein to provide information about me to Continuing Hope Counseling LLC. I understand that false statements made on this application are punishable. I certify that the statements regarding the persons and income in my household are true and correct to the best of my knowledge. I further understand if any information is found inaccurate, I may be denied a discount and/or subject to criminal prosecution for knowingly providing false information. I agree to notify Continuing Hope Counseling LLC of all changes in income, address, living arrangements, number of household members and/or other circumstances. I understand that the information given above will be kept confidential, except for the purposes noted above, and not released without my written permission. I also understand that if I do not agree with any decision made concerning this application, I have the right for a review in writing.
Printed Name

First NameLast Name
Signature

Clear
Should be Empty: