Midtown Family Services Application Form

About the Applicant

Please select your language.

Zip Code

ZIP

Justice System Involvement

Have you or anyone who currently lives with you served time in a California State prison within the past 4 years?

YesNo

Justice System Details

Do you have a CDCR number?

YesNo

Please enter your CDCR number

Please enter your parole officer's name

Disclaimer

At this time, Midtown Family Services does not have the capacity to serve persons living outside zip codes 95128, 95126, 95117, 95130 or 95008. If you are not in a local zipcode, we can still offer you an email with a list of resources for you to pursue.

What is your preferred language for this email?

English / InglesSpanish / Español

Please fill out this page to tell us about yourself.

Applicant Information

First Name

Last Name

Date of Birth

Phone

Street Address

City

State

County

Please check all that apply to you

College studentCurrent or former foster childCurrently homelessDisabledEmancipated youthFoster YouthImmigrantIntact FamilyPregnant (second or third trimester)Single ParentVeteranVictim of a crimeVictim of domestic violenceOther

What kinds of assistance do you or anyone in your household need? Check all that apply. We may ask you questions about some items you check in the following pages.

Assistance with bereavement costsAssistance with job searchAssistance with utilitiesBus passCounselingDeposit assistanceFoodFree/reduced price IDFurnitureHoliday giftsHotel/motel voucherHousingMedical equipment, eyeglasses, dentures, or similarOther AssistanceOther financial assistanceRe-entry servicesRent assistance

Ethnicity and Race information is not required and is never used to determine eligibility for assistance. We only use this information for reporting on equal opportunity statistics.

Ethnicity/Race

American Indian/Alaska Native

Black/African-American

Hispanic/Latino/SpanishAsian: ChineseAsian: JapaneseAsian: FilipinoAsian: KoreanAsian: VietnameseAsian: IndianAsian: LaotianAsian: CambodianAsian: OtherMiddle Eastern/North AfricanPacific Islander: Native HawaiianPacific Islander: SamoanPacific Islander: GuamanianPacific Islander: OtherWhiteDecline to StateMulti-ethnic origin, ethnicity, or raceOther identified ethnic origin, ethnicity, or race

Household Income

Income source(s) (check all that apply)

CalFreshCalWORKSSection 8 VoucherSSISubsidized HousingWICWorkOther

Monthly Net Income in dollars

Other Household Members

Do any other people live in your household?

NoYes

Other Agency Contacts

Have you contacted other agencies before coming to Midtown?

NoYes

Agencie(s) contacted

Outcome of visit(s)

Other Household Members

Some of the types of assistance you selected require us to collect information on other people who may live in your household. Filling out this information now may help us process your requests more quickly. This information may also help us identify additional resources to offer you.

Please enter all of the members of your household. You may click the Add another household member link to add additional people.

Other household member

First Name

Last Name

Date of Birth

Please check all options that describe this person:

College studentCurrent or former foster childCurrently homelessDisabledEmancipated youthFormerly incarceratedFoster YouthIntact FamilyJustice system involvedPregnant (second or third trimester)Single ParentVeteranVictim of a crimeVictim of domestic violenceImmigrant

Because you are the only member of your household, you may click Next Page to continue.

Bus Pass Application

No matter which selection you make below, we'll need you to come into the Midtown Family Services office to take a photo or pick up your pass.

Is this a new pass or a renewal?

NewRenewal - sticker onlyRenewal - pass plus sticker

For new passes, we'll need you to come into our office to sign an Release of Information form and take a photo that meets the County of Santa Clara's requirements.

You can click Next Page to continue,

For renewals that only include a sticker, we'll need you to come into our office to pick up the sticker after it arrives, which usually takes 4-5 business days. We will call you when you can come in, or if we need more information.

You can click Next Page to continue,

For renewal passes that need a new pass plus a sticker, we'll need you to come into our office so that we can take a photo that meets the County of Santa Clara's requirements.

You can click Next Page to continue,

Housing Assistance

Have you lived in your current county for more than two years, as of today?

NoYes

Residence less than two years

Former Address/County

Date moved to current county

Request Details

Request Type

Delinquent Rent/MortgageDeposit

First Month Rent

Other

Request Reason

Disability/Illness

Family Separation

Public AssistanceUnemploymentOther

Explanation

What other actions have been taken to alleviate the need?