Doors of Hope Emergency Assistance Application

This is a screening to see if you meet the requirements for Doors of Hope. If you do, we will be in touch within 3-5 days to discuss the next steps. Please DO NOT fill out the application more than once!

Requirements for Eligibility:

Before filling out the online application, please read the list of requirements below. If you are ineligible for our program, please call our office for a referral to an organization that can help you, (662) 234-1100.

Please allow us 3-5 days to respond to your application.

21 years of age or an emancipated adult aged 18 or over.
Must have minor children in the home & in your custody
Lafayette County resident for a minimum of 6 months, or a non-resident who has worked (and is currently employed) in Lafayette County for more than 6 months.

Applicant Name *

First

Middle

Last

Date of Birth *

Sex *

Male
Female

Please check your race and ethnicity. If bi-racial or multi-racial please check all that apply

White
Black/African American
Hispanic or Latino
Asian
American Indian/Alaska Native
Native Hawaiin/Other Pacific Islander
Other, not listed above

Applicant's Phone Number: *

Applicant's Email *

Current Address (or address of person you are staying with) *

Doors of Hope ONLY serves families with minor children in the home. Do you have legal custody of minor children? *

*IF YOU DO NOT HAVE MINOR CHILDREN IN THE HOME, PLEASE DISCONTINUE THE ONLINE APPLICATION. CALL 662-234-1100 FOR A REFERRAL TO AN ORGANIZATION THAT CAN HELP YOU.

Please list all children's names and ages that you have legal custody of and who live in the home with you: *

Are there other children that are not in the household? *

How long have you lived in Lafayette County? *

Under 6 months
6 months to 1 year
Over 1 year
I do not live in Lafayette County, but I am currently employed in Lafayette County (must be employed in Lafayette county for more than 6 months)
I do not live or work in Lafayette County***

*** IF YOU DO NOT LIVE OR WORK IN LAFAYETTE COUNTY, PLEASE DISCONTINUE THE ONLINE APPLICATION. CALL 662-234-1100 FOR A REFFERAL TO AN ORGANIZATION THAT CAN HELP YOU.

What caused your current situation? (Provide as many details as possible!) *

Do you have family in Lafayette County? If so, please list their relationship with you (ex: Mom, Dad, Grandmother, Uncle, etc.) *

Emergency Contact #1 *

First

Last

Phone Number *

Emergency Contact #2 *

First

Last

Phone Number *

Select your highest level of education: *

School *

Year Graduated *

What is your total household income? This includes all income from everyone in the household (including social security, child support, and paychecks)

Are you currently employed? *

Have you ever been fired? *

1. Employment History *

Job Title *

Supervisor Name *

Rate of Pay *

Reason for leaving? *

2. Employment History *

Job Title *

Supervisor Name *

Rate of Pay *

Reason for leaving? *

Have you applied for TANF? *

Do you have open child support cases? *

If you do have open child support cases, please list which child/children they apply to.

Have you applied for disability? *

Does anyone in the family have health insurance? *

Please list any present or outstanding debts/collections/judgements. *

Format this section by listing the item, lender, and amount due for each debt.

Does anyone in the household have posession of a vehicle? *

Clear title? *

Make and model of vehicle:

Year

Are your tags current? *

Do you have liability insurance? *

Do you have car seats as needed for children? *

Do you have any outstanding tickets, fines, or violations? *

If you have had any outstanding tickets or fines, please provide details (amount, location, date received, community service performed, etc.)

Have you ever been arrested? *

Please note that a criminal record will not immediately disqualify you from our program.

Have you ever had a child protective case filed against you? *

Are you involved in a current child protective case? *

List ALL of your arrests. (If you do not have an arrest record, please type N/A) Failure to provide this information may void application. *

List arrests by date, charge, sentence, time served, and where time was served.

Last release date:

County of Offense:

Are there any warrants out for your arrest? *

Yes
No
Unknown

Are there any restraining orders against you? *

Does anyone in your household have a history of drug and alcohol abuse? *

If yes, please indicate which household member, when the last use of drugs/alcohol was, and how much.

Please list any and all medical problems. *

Doors of Hope does not provide any medical or behavioral health benefits or treatment.

Are you presently using any prescription drug(s) for any condition listed above?

Are you or your spouse currently pregnant? *

If yes, when is the due date?

Is the pregnant individual currently receiving prenatal care through a medical professional?

Has anyone in your household been treated for a mental/emotional condition? *

Is this person currently using prescription drugs to treat this condition? *

If someone in the household has ever been treated for a mental/emotional condition, please describe the treatment plan. This includes the diagnosis, counseling services, where the counseling services take place, and the names of both their cousnelor and doctor. *

Have you ever lived in public housing? *

have you ever been banned from or denied public housing? *

If you have been banned or denied public housing, please tell us from where and why.

This is the beginning of the MONTHLY EXPENSES section. Please list all sources of income by answering the questions below. If it does not apply to you, please put N/A. Do you receive TANF, Food Stamps/SNAP? *

Child Support *

SS/SSI/SSDI *

Veteran's Benefits *

Unemployment *

Worker's/Workman's Comp *

Total in Checking and Savings *

Any other income/assets *

This is the MONTHLY EXPENSE portion. Please answer the questions below, if they do not apply to you, please put N/A. Utilities (Electricity, Gas, Water, Internet, etc.) *