Back on Track Client Information Form

23 August 2022   |   Posted in:

Please read the Back on Track Agreement and provide electronic signature authorization below before submitting this form.

IMPORTANT NOTES- PLEASE READ! 1. PLEASE FILL OUT THIS APPLICATION CAREFULLY AND INCLUDE ALL NECESSARY INFORMATION IN ITS ENTIRETY. INCOMPLETE FORMS WILL NOT BE CONSIDERED. 2. BACK ON TRACK IS A 'ONE-TIME' ASSISTANCE PROGRAM ONLY. IF CVCCS HAS PROVIDED MONETARY ASSISTANCE TO YOU PREVIOUSLY ANY NEW REQUESTS WILL NOT BE CONSIDERED. 3. THE CRITERIA FOR ASSISTANCE HINGES ON WHETHER YOUR SITUATION IS SELF-SUSTAINABLE. 4. OUR BACK ON TRACK COMMITTEE ONLY MEETS ONCE A WEEK TO DISCUSS APPLICATIONS.

  • MM slash DD slash YYYY
  • *Put NOT APPLICABLE if this question does not apply.
  • If no other household members, put NOT APPLICABLE.
  • For example- food, car, rent, phone, insurance, utilities, etc.
  • (Sources of income include earned income, SSI/DI, food stamps, TANF, etc.).
  • Max. file size: 128 MB.
  • Max. file size: 128 MB.
  • Max. file size: 128 MB.
  • Max. file size: 128 MB.
  • This field is for validation purposes and should be left unchanged.