North Dallas Shared Ministries Application for Assistance

Applicant Information

First Name:* Middle Name Last Name:*

Address:* Apt Number City:* TX Zip:*

Telephone Number where you can be called:* Type of phone:*

Social Security # Official Photo ID number: *

Sex (M/F):* Date of Birth:* Ethnicity:* Marital Status:*

Household Information
Total # of people living in household:

Where do you live:* DHA/Sec 8:*

Apt/Condo/Motel name: Apt Number

Landlord Name: Phone:*

One month's rent is? *$ Move-in Date:* (date moved on to property)

List Information regarding ALL OTHER ADULTS Age 18 or over living in your household:

DO NOT LIST YOURSELF BELOW - ANYONE ELSE LIVING AT RESIDENCE SHOULD BE LISTED

List Information for ALL CHILDREN under 18 living in your household:

How many are on Medicaid?* How many are on SNAP (food stamps, use numbers)* Monthly Amount from SNAP $

HOUSEHOLD INCOME INFORMATION

Total HOUSEHOLD Monthly Net Income?*$ (take home amount for all in household)

Source of Your Income?

Your Monthly Net Income:*$ (take home amount)

Your Current Employer's Name:* Phone:*

Your Current Employment Length? (example: 6 weeks, 7 months, years)* Days, Weeks, Months, Years:*

Other Monthly Income? $
Other Monthly Income? $

Anyone Else in Household Generating Income: *

ADDITIONAL PERSON'S INCOME INFORMATION

Source of His/Her Income?

Additional Person's Monthly Net Income: $ (take home amount)

Additional Person's Current Employer's Name: Phone:

Additional Person's Current Employment Length? (example: 6 weeks, 7 months, years) Days, Weeks, Months, Years:

Other Monthly Income? $
Other Monthly Income? $

Email Address:*

Enter Email Address Again:*

FINANCIAL ASSISTANCE NEEDED

What kind of help do you need?*

Amount you owe*$

Brief explanation of why you need this help?*

A RESPONSE WILL BE EMAILED TO YOU WITHIN 24 HOURS ONCE YOU SUBMIT.

PLEASE READ SCREEN AFTER YOU CLICK SUBMIT FOR IMPORTANT DIRECTIONS.

By submitting your mobile number, you agree to receive text messages from NDSM. You can opt-out anytime. Message and data rates may apply. Updated 8.8.2023.

You must live in one of the following zip codes to request financial assistance:

You must have sufficient verifiable income.

You must have a valid email.

Applicant Information

Household Information

List Information regarding ALL OTHER ADULTS Age 18 or over living in your household:

List Information for ALL CHILDREN under 18 living in your household:

HOUSEHOLD INCOME INFORMATION

ADDITIONAL PERSON'S INCOME INFORMATION

FINANCIAL ASSISTANCE NEEDED

A RESPONSE WILL BE EMAILED TO YOU WITHIN 24 HOURS ONCE YOU SUBMIT.

PLEASE READ SCREEN AFTER YOU CLICK SUBMIT FOR IMPORTANT DIRECTIONS.

You must live in one of the following zip codes to request financial assistance:

You must have sufficient verifiable income.

You must have a valid email.

Applicant Information

Household Information

List Information regarding ALL OTHER ADULTS Age 18 or over living in your household:

List Information for ALL CHILDREN under 18 living in your household:

HOUSEHOLD INCOME INFORMATION

ADDITIONAL PERSON'S INCOME INFORMATION

FINANCIAL ASSISTANCE NEEDED

A RESPONSE WILL BE EMAILED TO YOU WITHIN 24 HOURS ONCE YOU SUBMIT. PLEASE READ SCREEN AFTER YOU CLICK SUBMIT FOR IMPORTANT DIRECTIONS.

A RESPONSE WILL BE EMAILED TO YOU WITHIN 24 HOURS ONCE YOU SUBMIT.

PLEASE READ SCREEN AFTER YOU CLICK SUBMIT FOR IMPORTANT DIRECTIONS.