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Muslim Community Services of San Diego, Inc. ~ Office phone: 619 696 9267 Mailing address: 4203 Genesee Ave, #174 ~ San Diego, CA 92117

APPLICATION FOR SERVICES

DATE: ___/___/_________

Provide accurate information. Failure to do so may result in disqualification for services.

Name: _____________________________ Phone:(_____)_______________ Cell: (____)______________ Address:_______________________________________________________ Email:___________________ Street # Apt# City Zip CASE WORKER:______________________

Age:_____

Gender: M or F

Marital Status:_______________________

AGENCY:_________ PHONE:_________________

Languages Spoken:__________________________ Spouse’s name:________________________________

Children in home (names, age, gender):_______________________________________________________ Others living in home:_____________________________________________________________________ Employment:________________________

Rent:________

Water:____

Spouses Employment:___________________________

Phone(s):_______

Special needs:____________________________

Other monthly expenses (list):_________________________________ Estimated monthly income:_____________

Cash aid (gov):_________

SSI:_______

Est. amount:__________

Is there food in the house?_______________________

Disability:_____

Medical:________

Other assistance (list all orgs and amounts):____________________________________________________

Please briefly explain why you are requesting services: ___________________________________________

SIGNATURE:___________________________ OFFICE USE ONLY – NO WRITING IN THIS BOX PLEASE Notes:________________________________________________________________________________

Reviewed by: _____________________________________________________ Date:_______________ Requested action:_______________________________________________________________________


COMMENTS: 1. Circle all paperwork that you saw to confirm above information: LEASE/RENTAL AGREEMENT WELFARE PAPER

WATER BILL

FOOD STAMPS

CATHOLIC CHARITIES

SSI

PHONE BILL DISABILITY

SDGE MEDICAL

OTHER:_________________

2. Notes about what assistance this family has received/is receiving from other sources:

3. Transportation: Does this family have a car? Do they live close to a bus stop and are they able to take the bus? Do they need a bus pass? DO THEY NEED A RIDE TO JUMUAH? How many adult males in the household? 4. Does the family have a mushaf? Translation of Qur’an in their language?

5. Who at this address is working? Who is looking for work? What are their qualifications/skills? Are the sisters able to do homecare?

6. Any notes about how to find apartment/house:

7. Other comments:


MCSSD Application