Adopt-A-Family

WHAT IS THE REASON THAT YOU NEED HELP FOR CHRISTMAS?

Name

Phone

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Emergency phone

Emergency name

Emergency email

Household Members

Please List

Re-order	Full Name	Sex M/F	Relation to you	Date of Birth	Please List, Shirt Size, Shoe Size, Pant Size	Grade & School	Special Needs / 3 to 5 Gift Ideas For Santa	Weight	Operations
	Full Name	Sex M/F	Relation to you	Date of Birth	Please List, Shirt Size, Shoe Size, Pant Size Please List, Shirt Size, Shoe Size, Pant Size	Grade & School	Special Needs / 3 to 5 Gift Ideas For Santa	Item weight

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Do you need food assistance?

Specify types of food needed:

Do you need any basic household items? List items needed if adopter chooses to provide additional gifts (size when appropriate):

Head of Household Marital Status

Married

Divorced

Never Married

Widow(er)

Separated

Single

Race

White

Black

Hispanic/Latino

Native American

Asian

Multi-racial household

Military Service/Veteran

Air Force

Army

Guard

Marines

Navy

Reserves

Employment history of all adults

(Current and past year)

Re-order	Employee	Employer	Starting mo & year	End date/ Still working	$ per hour	# hours worked in a pay period	How often paid	Gross wages	Net wages	Weight	Operations
	Employee	Employer	Starting mo & year	End date/ Still working	$ per hour	# hours worked in a pay period	How often paid	Gross wages	Net wages	Item weight

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Does any household member have deductions/garnishments/child support taken from wages after taxes?

Yes

Garnishment/deduction

Re-order	Name	Type of garnishment/deduction	Weight	Operations
	Name	Type of garnishment/deduction	Item weight

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Does anyone in your household receive disability benefits?

Yes

Type or cause of disability

Re-order	Name	Type or cause of disability	Weight	Operations
	Name	Type or cause of disability	Item weight

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PERSON RECEIVING

DISABLILTY	NAME OF PERSON RECEIVING	HOW OFTEN PAID	HOW OFTEN PAID
Blind Pension	NAME OF PERSON RECEIVING	HOW OFTEN PAID	GROSS AMOUNT
Child Support or Alimony	NAME OF PERSON RECEIVING	HOW OFTEN PAID	GROSS AMOUNT
Military Allotment	NAME OF PERSON RECEIVING	HOW OFTEN PAID	GROSS AMOUNT
Money from relatives/organizations	NAME OF PERSON RECEIVING	HOW OFTEN PAID	GROSS AMOUNT
Pension/Retirement	NAME OF PERSON RECEIVING	HOW OFTEN PAID	GROSS AMOUNT
Rental/Property Income	NAME OF PERSON RECEIVING	HOW OFTEN PAID	GROSS AMOUNT
Social Security	NAME OF PERSON RECEIVING	HOW OFTEN PAID	GROSS AMOUNT
SSI/Disability Benefits	NAME OF PERSON RECEIVING	HOW OFTEN PAID	GROSS AMOUNT
TANF or Foster Care	NAME OF PERSON RECEIVING	HOW OFTEN PAID	GROSS AMOUNT
Unemployment Compensation	NAME OF PERSON RECEIVING	HOW OFTEN PAID	GROSS AMOUNT
Unemployed Fathers	NAME OF PERSON RECEIVING	HOW OFTEN PAID	GROSS AMOUNT
Utility Allowance from Housing	NAME OF PERSON RECEIVING	HOW OFTEN PAID	GROSS AMOUNT
Veteran’s Pension	NAME OF PERSON RECEIVING	HOW OFTEN PAID	GROSS AMOUNT
Workmen’s Compensation	NAME OF PERSON RECEIVING	HOW OFTEN PAID	GROSS AMOUNT
Other	NAME OF PERSON RECEIVING	HOW OFTEN PAID	GROSS AMOUNT
Blind Pension	NAME OF PERSON RECEIVING	HOW OFTEN PAID	GROSS AMOUNT

If adopted and necessary, could you come to our office to pick-up any gifts you might receive?

Yes

Is anyone in your household on probation or parole?

Yes

Who?

Name and phone of landlord, employer, or caseworker that can verify your information if necessary:

MONTHLY EXPENSES

MONTHLY EXPENSES	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
MORTGAGE/RENT (CIRCLE ONE) IF SUBSIDIZED: AMOUNT YOU PAY	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
CAR – YEAR – MAKE & MODEL	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
CAR – YEAR – MAKE & MODEL	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
INSURANCE – CAR # MONTHS PAYMENT COVERS	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
INSURANCE – HOME/RENTERS # MONTHS PAYMENT COVERS	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
INSURANCE – HEALTH # MONTHS PAYMENT COVERS	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
INSURANCE – LIFE # MONTHS PAYMENT COVERS	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
ELECTRICITY	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
GAS/PROPANE	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
WATER	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
SEWER	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
TRASH # MONTHS PAYMENT COVERS	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
CABLEVISION/INTERNET	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
HOME/CELL PHONE NUMBER OF PHONES	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
CREDIT CARD: NAME OF	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
PAYDAY/TITLE LOAN	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
LOAN: FOR WHAT	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
RENT-TO-OWN: ITEM(S)	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
FOOD – AFTER USING FOOD STAMPS	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
PRESCRIPTIONS/CO-PAYS	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
MONTHLY MEDICAL EXPENSES (CO-PAYS, DOCTOR PAYMENTS)	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
CHILD CARE (DAYCARE/BABYSITTER)	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
TRANSPORTATION: GAS/BUS/CAB (CIRCLE ONE OR MORE)	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
SCHOOL LUNCHES	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
SCHOOL LUNCHES	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
SCHOOL ACTIVITY EXPENSES	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
LAUNDROMAT EXPENSES	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
CLEANING SUPPLIES	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
PERSONAL HYGIENE (INCLUDE TANNING/NAILS)	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
DIAPERS	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
CIGARETTES	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE
PET FOOD	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE

OTHER (PLEASE LIST)

Re-order	MONTHLY EXPENSES	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE	Weight	Operations
	MONTHLY EXPENSES	CURRENT AMOUNT DUE	PAST DUE AMOUNT	SHUT OFF DATE	Item weight

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I understand that applying does not guarantee my family will be adopted. I understand this program is meant to help the children in the household. I understand the adult family members are not guaranteed they will receive any gifts. I hereby authorize and empower AFL-CIO Community Services or any individual selected by it, to examine any information relating to my records released to AFL-CIO Community Services and to disclose said records to any agency or individual in order to pursue my case. I further authorize release of information hereafter to AFL-CIO Community Services until I revoke this authorization in writing. I also understand and agree that a photocopy of this authorization shall be as valid as the original and be accepted with the same authority as the original. I certify that all the information I provided is true and correct to the best of my knowledge and understand that deliberate false or misleading information will be cause for refusal of services.

Signature

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