Domestic Violence Program Application Step 1 of 2 50% Name(Required) First Last Tribe(Required)Gender Female Male Prefer not to say Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Age(Required)Date of Birth(Required) Month Day Year Cell Phone(Required)Message Phone(Required)Email(Required) Do you reside on trust property?(Required) Yes No What is your current living situation?(Required) Own home Rent Living w/ family Living w/ friend Homeless Were you referred to our program?(Required) Yes No Who referred you?(Required)List everyone in your household.(Required)NameRelationshipAge Add RemoveDo not include yourself.Emergency Contact Name(Required) First Last Relationship(Required)Emergency Contact Phone(Required)Emergency Contact Email(Required) Emergency Contact Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you currently employed?(Required) Yes No Total work hours per week:(Required)Employer Name(Required)Phone(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is your employer aware of your domestic situation?(Required) Yes No Do you receive any income not from employment?(Required) Yes No Please list other income below and amount received a month.(Required)Type of IncomeAmount Received Per Month Add RemoveOther income may include TANF, SNAP, IIM, SSI, child support, unemployment, or alimony.List all monthly bills(Required)Type of BillAmount Per Month Add RemoveMonthly bills may include rent/mortgage, electric, water, gas/propane, car, and car insurance. Incident InformationPerpetrator Name(Required) First Last Relationship(Required)Incident Date(Required)Incident Location(Required)Was the incident reported to law enforcement?(Required) Yes No Which law enforcement agency?(Required)Will a protective order be filed?(Required) Yes No Do you need help filing?(Required) Yes No Services requested from Domestic Violence Program(Required) Emergency Shelter Victims Compensation Info. Family Counseling Drug & Alcohol Counseling Individual Counseling Behavioral Health Advocacy Domestic Violence Info. Transportation Children’s Services (referral) Rental Deposit Utility Deposit Rental Payment Utility Payment Groceries Hygiene Products Clothing Other Select AllCheck all that apply.Please explain the type of services you are requesting.(Required)Please explain the nature, extent, frequency, and duration of the alleged abuse, neglect, exploitation, or any physical injuries.(Required)Do you have photos of injuries?(Required) Yes No Please upload photos. Drop files here or Select files Accepted file types: jpg, png, gif, heic, Max. file size: 4 MB. Signature(Required)Date(Required) Month Day Year
