Dear Applicant:

Thank you for your interest to apply for financial assistance through the Tanner Community Development Corporation (TCDC) Cares Program due to the impact of COVID-19. As you prepare to apply for assistance, please ensure that you have the following documents available in order not to delay the verification of eligibility. Please provide the following items:

Completed Intake Application Verification of impact of COVID-19 crisis to household income(termination, furlough, reduced hours, proof of application for unemployment benefits) Driver’s license Passport photo Water bill Electric bill Gas bill Mortgage statement or rental agreement Statement of Disclosure

Thank you and we look forward to working with you during these challenging times.

COVID-19 CARES INTAKE FORM

Agency: TCDC Case Manager: _____________________

Date ____________________________________

1

Tanner Community Development Corporation (TCDC) will not discriminate, nor tolerate discrimination in employment or against any applicant, employee, because of race, color, religion, sex, sexual orientation, gender identity, national origin, citizenship status (including document abuse),

age, disability, veteran status or genetic information.

First Name Middle Initial Last Name SSN

Residential Street Address Residential County

City State Zip Code

DOB Gender Citizenship Status

U.S. Citizen Legal Resident Other

Covid-19 Crisis Type Phone Number Email Address

Optional Section – Use as needed Electricity Provider Electricity Account #

Gas Provider Gas Account #

Water Provider (Must be City of Phoenix) Water Account #

Mortgage Provider Mortgage Account #

Landlord/Rental Company Name Landlord/Rental Company Contact Info

Document Received Date Received Other Comments Identity Verification

Citizenship / U.S. Residency Verification

Electricity Utility Bill

Gas Utility Bill

Water Bill

Mortgage Statement or Rental Agreement

Identity Verification

Citizenship/U.S. Residency Verification

2

Tanner Community Development Corporation (TCDC) will not discriminate, nor tolerate discrimination in employment or against any applicant, employee, because of race, color, religion, sex, sexual orientation, gender identity, national origin, citizenship status (including document abuse),

age, disability, veteran status or genetic information.

Electricity Bill 3

Tanner Community Development Corporation (TCDC) will not discriminate, nor tolerate discrimination in employment or against any applicant, employee, because of race, color, religion, sex, sexual orientation, gender identity, national origin, citizenship status (including document abuse),

age, disability, veteran status or genetic information.

Water Bill4

Tanner Community Development Corporation (TCDC) will not discriminate, nor tolerate discrimination in employment or against any applicant, employee, because of race, color, religion, sex, sexual orientation, gender identity, national origin, citizenship status (including document abuse),

age, disability, veteran status or genetic information.

Gas Bill 5

Tanner Community Development Corporation (TCDC) will not discriminate, nor tolerate discrimination in employment or against any applicant, employee, because of race, color, religion, sex, sexual orientation, gender identity, national origin, citizenship status (including document abuse),

age, disability, veteran status or genetic information.

Mortgage Bill and or Rental Agreement 6

Tanner Community Development Corporation (TCDC) will not discriminate, nor tolerate discrimination in employment or against any applicant, employee, because of race, color, religion, sex, sexual orientation, gender identity, national origin, citizenship status (including document abuse),

age, disability, veteran status or genetic information.

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Verificacion de identidad_af_image: Verificacion de Ciudadania_af_image: Factura de Servicio Electrico_af_image: Factura de Agua_af_image: Factura de Gas_af_image: Declaracion de Hipoteca o Contrato de Alquiler_af_image: Verificacion de identidad: OffVerificacionDeCiudadania: OfffacturaServicioElectrico: OfffacturaServicioGas: OfffacturaServicioAgua: OffdeclaracionHipotecaAlquiler: OffCase Manager: Intake Date_af_date: First Name: Middle Name: Last Name: Last Four SSN: Residential Address: County: City: State: Zip Code: Date of Birth: Sex: Covid19 Crisis Type: Phone Number: Email Address: Electricity Provider: Electricity Account Number: Gas Provider: Gas Account Number: Water Provider: Water Account Number: Mortgage Provider: Mortgage Account Number: Landlord/Rental Company Name: Landlord/Rental Company Contact Info: electricityUtilityBillDateReceived: verificationCitizenshipDateReceived: verificationIDDateReceived: gasUtilityBillDateReceived: waterUtilityBillDateReceived: mortgageRentalAgreementDateReceived: AdditionalComments: citizen: Off