JEWISH FAMILY SERVICES OF BROWARD COUNTY 5890 S. Pine Island Road, Suite 201 Davie, FL 33328 P: 954-370-2140 APPLICATION FOR FINANCIAL ASSISTANCE – 2022 Date: 06/02/2022 Last Name: Vasquez First: Marianelly Sex: ☐M ☐F x ☐Other: x Marital Status: ☐Married ☐Single ☐Widowed ☐Divorced Date of Birth:08/29/1951 Country of Origin: Colombia Citizen of the United States? ☐ x Yes ☐ No Number of Years Lived in Broward County: 12 Address: 6575 w oakland park blvd 403 City: Lauderhill Zip Code: 33313 Email Address: [email protected] Phone: 7862905724 Previous JFS Contacts: List names of each person sharing the household and his/her relationship to you: (Example: Spouse, Mother, Friend, Child) Name Age Date of Birth Occupation Relationship To You Diego A Delgadillo 47 11/17/1974 web designer son Valeria S Degadillo 14 04/07/2007 student granddaughter Please list current and/or previous employment: Employer the north face sawgrass mills sunrise fl the gap sawgrassmills sunrise fl Dates 03/01/2018- current 12/01/2003-02/01/2018 How were you referred to Jewish Family Services? Tv News Please list the names of all other agencies that you have contacted for assistance and explain what type of assistance you received: Agency Type of Assistance PLEASE COMPLETE THE SECOND SHEET OF THIS FORM JEWISH FAMILY SERVICES OF BROWARD COUNTY 5890 S. Pine Island Road, Suite 201 Davie, FL 33328 P: 954-370-2140 HOUSEHOLD INCOME/EXPENSES PLEASE FILL IN THE AMOUNT YOU RECEIVE/SPEND PER MONTH FOR EACH OF THE FOLLOWING: INCOME Employment/Salary Unemployment Benefits Social Security/SSI/SSDI SNAP TANF Financial Support from Family/Friends Child Support/Alimony Veteran’s Benefits Worker’s Compensation Retirement/Pension/Annuities Interest/Dividends Additional Income Not Listed Amount $14 per hour $ $711 $ $ $ $ $ $ $ $ $ $ EXPENSES Mortgage/Rent HOA/Maintenance Electric Water/Sewer/Trash Property Taxes Property Insurance Phone/Internet/Cable Car Payment/Insurance/Gas Transportation Child Support/Alimony Medical Childcare/Tuition Amount $1650 $ $200 $ $ $ $350 $1040 $ $ $ $ $ x Are you living in Section 8 or Section 202 housing? ☐Yes ☐No If yes, what is your portion of the rent? $_____________ ASSETS PLEASE FILL IN THE CURRENT BALANCE IN EACH OF THE FOLLOWING ASSET ACCOUNTS. To substantiate these figures, please provide us with banks statements(s) and/or monthly brokerage reports for any of the asset accounts listed below. Amount Amount Checking Account $100 Stocks/Bonds $ Savings Account $ Mutual Funds $ I declare that the answers to the above questions are true and complete and I hereby give my consent to Jewish Family Service of Broward County to release or request the above information to community organizations that can provide further assistance. If information is falsely given, I understand that I may jeopardize my chance of receiving financial assistance. Applicant’s Signature: Marianelly Vasquez Date:06/02/2022 In addition to copies of any and all income and asset verifications, please return this form with copies of the following: ☐ Eviction Notice x Picture I.D. ☐ x Landlord Verification Form (enclosed) ☐ ☐ Other: ☐ Verification of medical condition x Bank statement ☐ ☐x Copy of utility bill
