Regular Application – Love INC Nacogdoches

About Love INC Nacogdoches
- About Us
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Client Intake Application

This application is for Nacogdoches County Texas residents ONLY.

Applications Take 7-10 Days to process. All requests must go through the application process.

For Angelina County call: (936)637-6637

To find a Love INC near you go to: https://www.loveinc.org/love-inc-locations/

For areas with no local Love INC go to: findhelp.org

We can NOT reconnect utilities. You will be required to pay late fees and reconnection fees before we will be able to help with your bill.

Name(Required)

First Middle Last

Birthday(Required)

MM slash DD slash YYYY

Gender(Required)

Marital Status(Required)

Phone Number(Required)

Alternate Phone Number

How did you hear about us?(Required)

Address(Required)

Street Address Address Line 2 City State ZIP / Postal Code

Do you rent or own?(Required)

Rent

Own

Landlord Name(Required)

Landlord Phone Number(Required)

Do you attend church?(Required)

Yes

Church Name(Required)

Household Members(Required)

Name

Relationship

Date of Birth

Gender

Press the plus sign (+) to add more members of your household.

How can we help you? Please select all that apply.(Required)

Harvest House Food Voucher

Hospice Shop Clothing Voucher

Hygiene Items

Cleaning Supplies

Furniture

Utility Bill (Electric or Water ONLY! No gas, phone, or internet bills)

Minor Home Repair

Medical Transportation (Elderly or Disabled ONLY)

I lost my job due to Covid-19

Prayer

Please describe your current situation and need for assistance.(Required)

Please upload a picture of your photo ID or drivers license.

Drop files here or

Max. file size: 2 GB.

Please upload a picture of your water utility bill.

Drop files here or

Max. file size: 2 GB.

Please upload a proof of your medical appointment.

Drop files here or

Max. file size: 2 GB.

Please list all needed furniture items.

Covid-19 caused me to lose my job or be off work in the last 6 months.

Yes

Covid-19 Assistance you would like to apply for:

Rent

Utilities

Please upload a picture of your lease.

Drop files here or

Max. file size: 2 GB.

Please upload proof of homeownership. (Deed, Tax Paperwork, etc.)

Drop files here or

Max. file size: 2 GB.

Please upload photos of the needed repair.

Drop files here or

Max. file size: 2 GB.

Have you applied with Love INC before?(Required)

Yes

When did you last apply?(Required)

MM slash DD slash YYYY

Have you requested or are you receiving help from anywhere else?(Required)

Yes

Where are you receiving help from?(Required)

Select All That Apply to You

Disabled

Able to Work

Veteran

Involved with Legal System

Last 4 Digits of Social Security Number

What is your job status?(Required)

I have a job.

I am unemployed.

I am retired.

Employer Name(Required)

Employer Phone Number(Required)

How often are you paid?(Required)

Weekly

Biweekly

Monthly

Other

How much do you earn at your job?(Required)

How much retirement do you receive each month?(Required)

Do you receive unemployment?(Required)

Yes

How much unempoyment do you receive each month?(Required)

When were you last employed?(Required)

Do you receive other income? Select all that apply.(Required)

SNAP

SSI/SSDI/RSDI

WIC

Housing/HUD/Section 8

Disability

Child Support

Veterans Benefits

Medicaid/Medicare

Cash Assistance

Other

SNAP(Required)

SSI/SSDI/RSDI(Required)

WIC(Required)

Housing/HUD/Section 8(Required)

Disability(Required)

Child Support(Required)

Veterans Benefits(Required)

Medicaid/Medicare(Required)

Cash Assistance(Required)

Other(Required)

Please upload pictures of each type of income (pay stubs, social security letter, SNAP benefits letter, etc.).

Drop files here or

Max. file size: 2 GB.

Please select all the expenses you currently have.(Required)

Rent

Utilities

Food

Car Loan

Insurance

Child Daycare

Other

How much do you pay for rent?(Required)

How much do you pay for utilities?(Required)

How much do you pay for food?(Required)

How much is your car payment?(Required)

How much do you pay for insurance?(Required)

How much do you pay for your child's daycare?(Required)

List your other expenses on the left and the amount on the right.(Required)

Type of Expense

Expense Amount

How can we pray for you?(Required)

Consent(Required)

I agree to the below statement. All of the information on this form is true.

Information you provide in connection with this application is subject to verification by Love In the Name of Christ (Love INC). Love INC may contact other persons, agencies, businesses, and organizations for verification. All applicants are subject to a criminal history background check through the Texas Department of Public Safety’s Computerized Criminal History System. “I certify under penalty of perjury that the information I have provided on this application is true and complete to the best of my knowledge. If it is not, my request may be denied. I understand that Love INC may make an on-site visit to my residence."

Newsletter Email List

First Name *

Last Name *

Email *

Select list(s) to subscribe toOnline Newsletter

Example: Yes, I would like to receive emails from Love Inc.. (You can unsubscribe anytime)

Constant Contact Use. Please leave this field blank.

By submitting this form, you are consenting to receive marketing emails from: Love In the Name of Christ of Nacogdoches, P.O. Box 630423, Nacogdoches, TX, 75963, http://www.loveincnac.org. You can revoke your consent to receive emails at any time by using the SafeUnsubscribe® link, found at the bottom of every email. Emails are serviced by Constant Contact

OFFICIAL LOVE INC AFFILIATE

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