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Combined
Community Action
165 West Austin . Giddings TX 78942
979.540.2980 . 800.688.9065 . Fax 979-542.9565
www.ccaction.com
Pandemic Pre Application -- Pre-Aplicacion Pandemia
Date/ Fecha: _________________
Name/Nombre: ________________________
Phone Number/Numero ____________________
We must be able to contact you
Tenemos
que poder localizarlo
Address/ Direccion: __________________________________________________________________________
(Apt#) City/Ciudad ZIP/ Codigo postal
Composición Y Características del Hogar – Apunta el
nombre de la persona responsable del hogar y todas
las personas que viven en el hogar. Indica cual e
s la
relación de cada miembro a la persona responsable
del hogar.
Household Members
Miembros del Hogar
Race
Raza
Sex
Sexo
Education
Level
Nivel de
Educacion
Social Security Number
Numero de Seguro
Social
SELF/MISMO
Información de Ingresos – Incluya sueldo, salario, Compensación de Desempleo, ingresos de
tiempo parcial, ingresos estacionales, Seguro Social, Ingreso de Seguridad Suplemental y
cualquier otro tipo de ingresos o beneficios que el hogar está recibiendo. (pertenece a los 30
días mas reciente)
Nombre de Miembros del hogar
Fuente de Ingresos
(Incluya el nombre del empleador
Last 30 days Income Amount
I CERTIFY T
HAT THE INFORMATION PROVIDED ON THIS APPLICATION IS TRUE AND CORRECT TO THE
BEST OF MY KNOWLEDGE AND BELIEF
______________________
_______________________ _____________________________
SIGNATURE/ FIRMA DATE/ FECHA
Applicants will be required to
show proof how Covid-19 has
impacted their household
DOB
Fecha de
Nacimiento
Relation to Head
of Household
Relacion a la persona
responsable del
hogar
County/ Condado
___________________________________
Household Member Name
Source of Income
Cantidad de ingresos (30 dias mas
reciente)
INCOME INFORMATION – Includes wages, salaries,
unemployment benefits, part-time inc
ome,
seasonal income, Social Security, Supplemental Security, and any
other income or benefits your
household may receive.
HOUSEHOLD COMPOSITION & CHARACTERISTICS – List the Head of Household
and all other persons who will be living in the home. Indicate the relationship
of each family member to the Head
of Household. Indicate the relationship of each family member to the Head of
Household.
SELECT/INDICA
Are you currently quarantined to your residence? Yes/Si ___ No_____
Has your income been effected by Covid-19? Yes/Si _______ No_______
If yes, where are you currently staying?
DESCRIBE NEED FOR ASSISTANCE/ DESCRIBA QUE ASISTENCIA NECESITA – Please explain why you are
currently in need of assistance and what you need assistance with. Por favor escriba una explicación
porque necesita ayuda y cuáles s
on las necesidades que requiere asistencia:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
___________________________________________________________________________________
You may return your application in the following way--Puede entregar su aplicación en las
siguientes maneras:
Por Correo:
COMBINED COMMUNITY ACTION, INC.
Attn: Family Services Dept
165 West Austin Street Giddings, Texas 78942
Por Fax: 979.542.9565 Cuando mande por fax o si escanea – por favor incluya ambos lados.
Todas las páginas deben de ser mandadas de una sola vez. When faxing or scanning - please include
front and back. All pages of faxes must be faxed at one time.
Correo electrónico:
jripper@ccaction.com y/o aperez@ccaction.com
Completion of this request does NOT guarantee assistance. Assistance is based on applicant being
eligible and AVAILABILITY of funds. An incomplete pre-application can be DENIED. Additional
information may be required.
CCA se comunicará con usted por teléfono cuando citas son planeadas. Completando esta solicitud
NO garantía asistencia. Asistencia es basada si el solicitante es elegible, DISPONIBILIDAD de fondos y
disponibilidad de citas. Una solicitud incompleta puede ser NEGADA. Si le dan una cita, más
información será necesaria. Si tiene preguntas adicionales por favor comuníquese con nuestra
agencia
Revised: March 31, 2020
¿Alguien en la casa está en cuarentena?
¿Sus ingresos fueron afectados por Covid-19?
¿Si indico que SI, indica con quien está(n) quedándose?__________________________
___________________________
By Mail
By Fax
By Email
SELECT
INDICA
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Completed 2 September 2021

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