Back on Track Client Information Form

23 August 2022 | Posted in: Posts

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.

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.

Back on Track only serves clients that live in the CV School District. Do you live in the CV School District?*
- Yes
- No
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Social Security #*
Phone*
Email*
Current Address*
Street Address Address Line 2 City State ZIP Code
How long have you been at your current address?*
Please list ALL sources of income for household members and amounts for each*
Sources of income include earned income, SSI, disability, food stamps, TANF, etc.
Please list ALL your expenses and amounts for each expense*
For example- food, car, rent, phone, insurance, utilities, etc.
Are you behind on any bills?*
- Yes
- No
List which bill(s) you are behind on and past due amount(s).
Please specify WHY you are unable to pay rent and/or bills. Provide SPECIFIC reasons and details.*
*Put NOT APPLICABLE if this question does not apply.
Have you received assistance from anyone else?*
- Yes
- No
If YES, who was the assistance from, how much did you receive, and when did you last receive it?
Are you currently employed?*
- Yes
- No
IF YES, how many hours per week do you work?
IF YES, please provide employers name and contact information
List all other household members, their ages, and their relationship to you*
*If no other household members, put NOT APPLICABLE.
Do you attend a local church?*
- Yes
- No
IF YES, what church?
IF NO, would you be interested in CVCCS connecting you with a local church?
- Yes
- No
How did you hear about CVCCS' Back on Track program?*
I verify that the information I’ve provided is accurate. I have read, agree, and give my electronic signature authorization for the Back on Track Agreement:*
- I Agree
I understand that if CVCCS provides me with financial assistance, I will be REQUIRED to attend at least 3 FREE financial/budgeting counseling sessions with CVCCS.*
- I agree
***Upload a picture of your lease agreement (must include your name, landlord, and signature page) and/or bill.
Max. file size: 128 MB.
***Upload a picture of your most current paystub if employed or last pay stub from prior employer.
Max. file size: 128 MB.
***Upload any bills you are behind on (For example- gas, electricity, car, etc.).
Max. file size: 128 MB.
***Upload any additional income statements (For example- SSI, disability, etc.).
Max. file size: 128 MB.
Upload anything additional (if needed).
Max. file size: 128 MB.
Upload anything additional (if needed).
Max. file size: 128 MB.
Upload anything additional (if needed).
Max. file size: 128 MB.
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2420 Gehman Lane, Lancaster, PA 17602
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Conestoga Valley Christian Community Services is a faith based 501c3 non-profit organization.