United Way of Onslow County- Center for Financial Stability
Client Enrollment Form
Please read, understand, and agree to the Terms and Conditions of this enrollment form
before signing. Please carefully review and complete all sections of this application. Please
print with ink pen. Return the completed application to your Financial Empowerment Coach.
DATE: ___________________
COACH NAME: ____________________________
Please provide the following information to the Financial Empowerment Coach:
Client Initial & Coach Initial: (Coach to make a copy of the driver’s license)
______
______ Driver’s License/State Issued ID
______
______ Social Security Card
CLIENT INFORMATION
Name: _______________________________
Social Sec. No: _____ - _____ - ______
Street: ____________________________________________ Apt #: ______
City: _____________________________________
State: ______
Home: (_______) ________- __________
Work:
Cell:
Zip Code: ___________
(_______) ________- __________
(_______) ________- __________ E-Mail:___________________________________
Gender:  Female
Veteran:  Yes
 Male
 No
Date of Birth: ________ / _______/________
Disabled:  Yes
 No
Ethnicity (please check one):
 African American  American Indian  Asian/Pacific Islander
 Caucasian
 Latino or Hispanic  Other (please specify: ________________)
Applicant’s marital status (please check one):
 Single
 Married
 Separated
 Divorced  Widowed
Highest Level of Education Completed (please check one):
 Grade K-5
 Grade 6-8
 Grade 9-12
 Some College
 2-year Degree
 4-year Degree
 High School Diploma or GED
 Attended Graduate School
Primary Employment Status (please check one):
 Employed more than full-time (overtime, or working more than one job)
 Employed full-time (35-40 hours)
 Currently in school or job training
 Employed part-time (up to 35 hours)
 Homemaker
 Working and in school or job training
 Disabled, not seeking employment
 Currently seeking employment
 Retired, not seeking employment
 Laid off/waiting for call back
 Retired, with other employment
EMERGENCY CONTACT INFORMATION
Please list a relative or friend who would definitely know how to contact you even in you move
Name: _______________________________
Phone: (_______) ________- __________
Street: ____________________________________________ Apt #: ______
City: _____________________________________
Relationship:  Relative: ____________
State: ______
 Friend
Zip Code: ___________
 Other: ____________
PERSONAL DETAILS
What type of bank account do you have?
Have you ever used direct deposit?
Do you own a vehicle?
Do you own a business?
Have you ever received an EITC Refund?
(Earned Income Tax Credit)





Checking
Yes
Yes
Yes
Yes





Savings
No
No
No
No
 Both
 None
Does anyone in your household receive? (Check all that apply)
 Veteran’s Benefits  Social Security Benefits  Unemployment
 Food Stamps
 Medicare/Medicaid
 TANF
Have you received any of the following in the last 3 months? (Check all that apply)
 Rental Assistance (Date: _____________ Source: __________________)
 Utility Assistance (Date: _____________ Source: __________________)
 Food Assistance
(Date: _____________ Source: __________________)
 Other (please specify the type, date, and source: __________________________________
GOALS
What would you like to achieve by working with your Financial Empowerment Coach?
_________________________________________________________________________________
_________________________________________________________________________________
Do you have any goals that would improve your future financial success?
_________________________________________________________________________________
_________________________________________________________________________________
What type of assistance do you need?
 Rental Assistance
 Mortgage Assistance
 Credit Counseling
 Money Management
 Benefits Assistance
 Utility Assistance
 Food Stamps
 Health Insurance
 Medicare/Medicaid
 Career Counseling
 Income Tax Filing
 Purchasing a Home
 Other (please describe): _________________________________________________________
EMPLOYMENT INFORMATION
PRIMARY EMPLOYER
Employer (Company) Name:
____________________________________________________
Work Address: __________________________________________________________________
City: _____________________________________
Phone: (_____)_____-________
State: ______
Date of Hire: _____________
Zip Code: ___________
Part-time or Full-time (Circle)
Position Title:___________________________ How Long in Position? ________
Monthly Gross Income (before taxes): $___________________
SECONDARY EMPLOYER
Employer (Company) Name:
____________________________________________________
Work Address: __________________________________________________________________
City: _____________________________________
Phone: (_____)_____-________
State: ______
Date of Hire: _____________
Zip Code: ___________
Part-time or Full-time (Circle)
Position Title:___________________________ How Long in Position? ________
Monthly Gross Income (before taxes): $___________________
THIRD EMPLOYER
Employer (Company) Name:
____________________________________________________
Work Address: __________________________________________________________________
City: _____________________________________
Phone: (_____)_____-________
State: ______
Date of Hire: _____________
Zip Code: ___________
Part-time or Full-time (Circle)
Position Title:___________________________ How Long in Position? ________
Monthly Gross Income (before taxes): $___________________
TOTAL MONTHLY GROSS INCOME (BEFORE TAXES) OF ALL EMPLOYMENT: $ ____________
HOUSEHOLD INFORMATION
Do you own or rent your current dwelling?
 Own
 Rent
Have you or anyone in your household owned/
co-owned any property in the past three years?
 Yes
 No
Landlord Name/Mortgage Company: _________________________________________________
Address: _________________________________________________________________________
City: _____________________________________
State: ______
Zip Code: ___________
Phone: (_____)_____-________
How long have you lived at your current address? _____ Years ____Months
Have you or anyone in your household ever been subject to any foreclosures, collections, or
judgments?  Yes
 No
If Yes, please explain: ________________________
_________________________________________________________________________________
Household type:
 Single Adult
 Female-headed Single Adult
 Male-headed Single Adult
 Married without children  Married with children
 Two or more unrelated adults
 Other: ________________________________________________________________________
Total number of your household: ______
Full Name
Adults: _____ Children: _____
Relation
Does your household have health insurance?
If so, what kind?
Date of Birth
Adults:  Yes  No
Disabled? Y/N
Children:  Yes  No
 Through Employer
 Self-Purchased
 NC Health Choice (Children)
 Other: ________________
FINANCIAL INFORMATION
IMPORTANT! This information should include income for ALL members of your household
Total GROSS (before taxes) income (all household members)
$ _______________
Child Support/Alimony
$ _______________
SSI/Social Security
$ _______________
Disability Income
$ _______________
Investments/Dividends Income
$ _______________
Pensions/Retirement Income
$ _______________
Other Income
$ _______________
TOTAL OF ALL INCOME
$ _______________
Name of Bank/Credit Union: ___________________________
Account Types: ___________
Name of Bank/Credit Union: ___________________________
Account Types: ___________
DEBTS
Loans/Credit Cards/Auto Loan/Child Support
Monthly Payment
Outstanding Balance
1. _________________________________
$ ____________
$ _______________
2. _________________________________
$ ____________
$ _______________
3. _________________________________
$ ____________
$ _______________
4. _________________________________
$ ____________
$ _______________
5. _________________________________
$ ____________
$ _______________
6. _________________________________
$ ____________
$ _______________
7. _________________________________
$ ____________
$ _______________
8. _________________________________
$ ____________
$ _______________
9. _________________________________
$ ____________
$ _______________
10. _________________________________
$ ____________
$ _______________
INCOME TAX INFORMATION
How are your income taxes prepared?
 VITA
 Self-prepared
 Paid Preparer
Other (please explain): ____________________________________________________________
Did you receive a refund last year?
 Yes
 No
CO-CLIENT INFORMATION
Name: _______________________________
Social Sec. No: _____ - _____ - ______
Street: ____________________________________________ Apt #: ______
City: _____________________________________
State: ______
Home: (_______) ________- __________
Work:
Cell:
Zip Code: ___________
(_______) ________- __________
(_______) ________- __________ E-Mail:___________________________________
Gender:  Female
 Male
Date of Birth: ________ / _______/________
Relationship to primary Client: ________________________________
Veteran:  Yes
 No
Disabled:  Yes
 No
Ethnicity (please check one):
 African American  American Indian  Asian/Pacific Islander
 Caucasian
 Latino or Hispanic  Other (please specify: ________________)
Applicant’s marital status (please check one):
 Single
 Married
 Separated
 Divorced  Widowed
Citizenship:  US Citizen
 Permanent Resident
 Other
Highest Level of Education Completed (please check one):
 Grade K-5
 Grade 6-8
 Grade 9-12
 Some College
 2-year Degree
 4-year Degree
 High School Diploma or GED
 Attended Graduate School
Primary Employment Status (please check one):
 Employed more than full-time (overtime, or working more than one job)
 Employed full-time (35-40 hours)
 Currently in school or job training
 Employed part-time (up to 35 hours)
 Homemaker
 Working and in school or job training
 Disabled, not seeking employment
 Currently seeking employment
 Retired, not seeking employment
 Laid off/waiting for call back
 Retired, with other employment
CO-CLIENT EMPLOYMENT INFORMATION
PRIMARY EMPLOYER
Employer (Company) Name:
____________________________________________________
Work Address: __________________________________________________________________
City: _____________________________________
Phone: (_____)_____-________
State: ______
Date of Hire: _____________
Zip Code: ___________
Part-time or Full-time (Circle)
Position Title:___________________________ How Long in Position? ________
Monthly Gross Income (before taxes): $___________________
SECONDARY EMPLOYER
Employer (Company) Name:
____________________________________________________
Work Address: __________________________________________________________________
City: _____________________________________
Phone: (_____)_____-________
State: ______
Date of Hire: _____________
Zip Code: ___________
Part-time or Full-time (Circle)
Position Title:___________________________ How Long in Position? ________
Monthly Gross Income (before taxes): $___________________
THIRD EMPLOYER
Employer (Company) Name:
____________________________________________________
Work Address: __________________________________________________________________
City: _____________________________________
Phone: (_____)_____-________
State: ______
Date of Hire: _____________
Zip Code: ___________
Part-time or Full-time (Circle)
Position Title:___________________________ How Long in Position? ________
Monthly Gross Income (before taxes): $___________________
TOTAL MONTHLY GROSS INCOME (BEFORE TAXES) OF ALL EMPLOYEMENT: $ ____________
United Way of Onslow County- Center for Financial Stability
Pathway to Prosperity Agreement- Terms & Conditions
ATTENTION CLIENT(S): Please read all of the statements below carefully before signing this application. Your Financial
Empowerment Coach can answer any questions you may have.
This agreement is between the United Way of Onslow County Center for Financial Stability, hereafter referred to as “The
Center”, and _______________________________________, hereafter referred to as “The Participant.”
The Participant understands and agrees that he/she will make all necessary appointments, attend all sessions, and adhere
to all requirements to participate in the program, which include (please initial for each item):
_________
I/We agree to participate in the Center’s program for a minimum of 1 (one) year, recognizing the time
it takes to achieve financial stability.
_________
I/We will meet regularly with my assigned Financial Empowerment Coach for one-on-one one budget
and financial counseling sessions as scheduled in advance, in addition to attending quarterly Financial
Literacy Workshop while enrolled with the Center.
_________
I/We will show up to workshops/sessions on time, complete any at-home assignments, and meet all
other requirements of any workshop/session to which I attend. I/We understand that non-compliance is
a reason for being terminated from the program. If I/We know ahead of time that I will miss a
workshop/session, I/we will contact my Financial Empowerment Coach at least 24 hours in advance of
the scheduled workshop/session except in the case of emergency.
_________
I/We have read all pages of this application and represent that all information provided is true and
accurate to the best of my knowledge. I/We understand the terms and conditions stated. My/Our
signature(s) below attest that I/We are in compliance with all terms set forth herein. I/We
understand that any intentional misrepresentations can be grounds for termination from the program.
_________
I/We hereby authorize the Center, or its assigns, subcontractors, and third party processors, to obtain
and verify any and all information regarding my/our employment, checking and/or savings accounts,
credit obligations, and all other credit matters which they may require in connection with this
application.
_________
I/We authorize the Center to order an in-file and/or consumer credit report and verify other credit
information including past and present mortgage or landlord references. It is understood that a copy or
fax of this form will also serve as authorization. This information is to be used for program purposes
only.
_________
I understand that each Financial Empowerment Coach signs a client confidentiality agreement, and the
coach doesn’t discuss your personal information with anyone you haven’t authorized. We value the
trust you place in us and we will not violate your trust.
The Center agrees:
1.
To provide personal finance and money management workshops for the Participant’s benefit at times as
convenient as possible for the Participant.
2.
To provide information and referral for additional opportunities to further become self-sufficient such
as educational/vocational training or opportunities through other community resources
3.
To work with the Participant to address any barriers for completing all of the requirements of this
Pathway to Prosperity Agreement.
I/We understand the terms and conditions set forth above, and agree to follow my/our Pathway to Prosperity as
prescribed above.
Print
Sign
______________________________
Participant Name
______________________________
Participant Signature
__________
Date
______________________________
Co-Participant Name
______________________________
Co-Participant Signature
__________
Date
______________________________
Financial Empowerment Coach Name
______________________________
Empowerment Coach Signature
__________
Date