INTAKE FORM
Date	Return to
Intake by	Deadline
Client	Household Size
Name, address, phone	Children under 18
Social Security Number	Adults 18 - 59
Date of Birth	Seniors 60 and over
Sex	Total
Children	Birth date	Children	Birth date
Monthly Income	Amount	Major Expenses	Amount
Total monthly income
Net (income-expenses)
125% of Poverty (Month)
Ethnicity	Language/translator
Citizen	Rent amount
Mortgage foreclosure	Sheriff's sale
Adverse Parties
Name, address, phone
Notes