Hot Spot Recertification Form

Hot Spot Recertification Form

Please complete this form to keep your hot spot. This information will be provided to Community Action Akron Summit as part of the grant funding the hot spots.

First Name

Last Name

Date of Birth

Gender

Male

Female

Address

City

State

Zip Code

Phone Number

Phone

Email

Ethnicity

Black

White

Hispanic

Native American

Asian

Other

Highest Completed Education Level

0 - 8

9 - 12

High School Diploma/GED

12+

UKN

College Diploma

Household Type

Single Parent Female

Single Parent Male

Two Parent

Single Person

Couple

Other

Source of Income

Employment

Unemployment

Social Security

TANF

SSI/SSDI

Pension

Self-Employment

Utility Assistance

Other

Head of Hosuehold Veteran Status

Yes

No

Head of Hosuehold Housing Type

Rent

Own

Head of Household Recieving Food Assistance

Yes

No

Head of Household Income Amount

Head of Household Income Frequency

Weekly

Bi-Weekly

Monthly

Bi-Monthly

Head of Household Insurance Type

Medicaid

Medicare

Private

None

I HEREBY CERTIFY THAT THE ABOVE INFORMATION PROVIDED IS TRUE TO THE BEST OF MY KNOWLEDGE AND ALLOW ASCA INC. TO USE DATA FROM INFORMATION PROVIDED ON THIS APPLICATION FOR REFFERRAL AND REPORTING PURPOSES AND TO VERIFY THE ACCURACY OF THE INFORMATION.

Digital Signature

This form may be submitted electronically and any electronic signatures appearing on this form shall have the same validity, enforceability, and admissibility as if hand written.

Signature Date

Send me a copy of my responses

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