Intake Form

Intake Form

Intake form Love INC Form Preview
  • Client Request Form

    Love INC of Greater Merced
  • Please make sure to agrre to our terms of service and note that all questions with an * must be answered or you will not be able to sumbit your form.

  •  -  - Pick a Date
  •  -  - Pick a Date
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  •  -  - Pick a Date
  • Do you...


     

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  • If Yes, please fill out below. If No, leave blank move on to Rent or Mortgage amount.

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  •  -  - Pick a Date
  • FURNITURE REQUESTS ONLY!

  • Income & Expense evaluation section

    Please type numbers only, this is for monthly income totals.
  •   Client's Amt. Mate's Amt. Other
    Food Stamps
    Cash Aid
    Disability
    Vet's Disability
    Other Grants
    Medi-Cal/Medicare
    WIC
    Self-Employment
    Wages(Net)
    Unemployment
    Social Security (Retirement)
    Retirement/Pension
    Veteran’s Retirement
    Child Support/Alimony
    Other
  •   Client's Amt. Mate's Amt. Other
    Rent/Mortgage
    Electricity/Gas(PG&E/MID)
    Other Utilities(W/S/G)
    Phone
    Internet/Cable
    Groceries/Food
    Car Payment
    Car Insurance
    Credit Card/Loans
    Eating Out/Movies
    Toiletries (hygiene, etc.)
    Haircuts/Beauty/Nails
    Gas/Bus/Transportation
    Health Insurance
    Medical Bills/Prescriptions
    Clothing, Shoes, etc.
    Payday/Rent to own Loans
    Education(books, supplies)
    Child Support/Alimony
    Other (Cigs./Alcohol)
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  • Details about Need

  • Future Direction

  • Verification Documents

    In order to verify the information you provide we will need proof of income and proof of residence. Verifications of income inclide copies of all forms of income in the household (SSI, Wages, Disability, Grants, TANF, etc.) Verifications of residence include the front page of a Rental/Lease Agreement--this is required for furniture requests --OR a current PG&E bill. You can upload legible photos of the necessary documents below.

  • We hope you have been encouraged by getting an opportunity to share your story. As we work with you over the next few days, we want to encourage you, believing that God values you and wants to improve your life.

  • Please sign to approve this document (click and hold mouse to draw signature, or with finger on mobile)

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