Budget For Life Program Eligibility Application

Program Eligibility Questions

Do you have a lease or mortgage in your name?

YesNo

Have you paid three full months of rent or mortgage from your move-in date?

YesNo

Are you current on your rent or mortgage?

YesNo

Is at least one adult household member working full-time (35 hours a week)?

YesNo

Do you have debt such as credit cards, loans, car notes, past evictions, or medical bills?

YesNo

Do you earn enough to pay your household expenses, not your debts?

YesNo

Have you ever participated in BCM Georgia’s financial education program (Budget for Life or 70/30 Project)?

YesNo

Thank you for completing the budget for life questionnaire. Based on your responses, you are currently not eligible for the financial education program.

Additional Resources:

United Way Atlanta: Visit www.unitedwayatlanta.org, scroll down, and select 2-1-1 Online under Other Resources to explore additional assistance.
Speak to a Specialist: Dial 2-1-1 or (404) 614-1000 for direct assistance.

ARCHI Rent, Mortgage, Utility Relief:

Apply directly to ARCHI for assistance:

Pre-Screen Application

Applicant’s Contact Information

Client Full Name

Email Address

Address: Street

Address: City

Address: State

Address: ZIP Code

Address: County

Do you have health insurance? If yes, provide the provider's name

Telephone Numbers: (H)

(W)

(c)

Age

Date Of Birth

Gender

Race

Ethnicity

Marital Status

Substance Abuse History- If yes please explain

Are you a veteran?

Highest Level of Education

Household Information

How many adults live in your home?

How many children live in your home (18 yrs. or younger)?

Do you have a lease or mortgage?

Are you current on your rent or mortgage

How many months have you been living at this address?

how much do you owe?

How many months are you behind?

ADULT HOUSEHOLD MEMBER INFORMATION

Adult Household Member Name

Adult Member Age

Date of Birth

What is the relationship to the applicant?

Substance Abuse History- If yes please explain

Highest Level of Education

Gender

Race

Ethnicity

Is the adult household member employed?

Does this adult household member have health insurance? If yes, provide the provider's name

ADULT HOUSEHOLD MEMBER INFORMATION

Adult Household Member Name

Adult Member Age

Date of Birth

What is the relationship to the applicant?

Substance Abuse History- If yes please explain

Highest Level of Education

Gender

Race

Ethnicity

Is the adult household member employed?

Does this adult household member have health insurance? If yes, provide the provider's name

Children in the household (18 years-old and younger)

Child's Name

Child's Age

Date of Birth

How is this child related to the Appliant?

Gender

Race

Ethnicity

Highest Level of Education

Does this child have health insurance? If yes, provide the provider's name

Children in the household (18 years-old and younger)

Child's Name

Child's Age

Date of Birth

How is this child related to the Appliant?

Gender

Race

Ethnicity

Highest Level of Education

Does this child have health insurance? If yes, provide the provider's name

Children in the household (18 years-old and younger)

Child's Name

Child's Age

Date of Birth

How is this child related to the Appliant?

Gender

Race

Ethnicity

Highest Level of Education

Does this child have health insurance? If yes, provide the provider's name

Children in the household (18 years-old and younger)

Child's Name

Child's Age

Date of Birth

How is this child related to the Appliant?

Gender

Race

Ethnicity

Highest Level of Education

Does this child have health insurance? If yes, provide the provider's name

Children in the household (18 years-old and younger)

Child's Name

Child's Age

Date of Birth

How is this child related to the Appliant?

Gender

Race

Ethnicity

Highest Level of Education

Does this child have health insurance? If yes, provide the provider's name

Client Employment Information

Current employer

Name of your current supervisor

Title/Position

Hourly rate or monthly pay (after taxes)

Number of hours per week

City

State

Employment Start Date

Past employer

Name of your past employer

Name of your past supervisor

Title/Position

Hourly rate or monthly pay (after taxes)

Number of hours per week

Reason for leaving

City

State

Start Date of Employment

End Date of Employment

Are any of the other adults in the household currently employed?

Current Employers for Other Adults in the Home

Name of Other Adult

Current Employer Name

Supervisor

Title/Position

Hourly rate or monthly pay (after taxes)

Number of hours per week

Start Date of Employment

End Date of Employment

City

State

Banking Information

Do you have a Checking Account?

Do you have a Savings Account?

Monthly Expenses

Rent

Amount DUE each month

Subsidized?

YesNo

Amount Paid Last month

Electricity

Amount DUE each month

Amount Paid Last month

Natural Gas

Amount DUE each month

Amount Paid Last month

Water

Amount DUE each month

Amount Paid Last month

Telephone/Cellular Service

Amount DUE each month

Amount Paid Last month

Cable

Amount DUE each month

Amount Paid Last month

Internet

Amount DUE each month

Amount Paid Last month

Groceries

Amount DUE each month

Amount Paid Last month

Eating Out

Amount DUE each month

Amount Paid Last month

Medical

Amount DUE each month

Amount Paid Last month

Car Insurance

Amount DUE each month

Amount Paid Last month

MARTA/Gas

Amount DUE each month

Amount Paid Last month

Car Loan

Amount DUE each month

Amount Paid Last month

Other Transportation Costs

Amount DUE each month

Amount Paid Last month

School Loans

Amount DUE each month

Amount Paid Last month

Title Loan

Amount DUE each month

Amount Paid Last month

Credit Card

Amount DUE each month

Amount Paid Last month

Furniture

Amount DUE each month

Amount Paid Last month

Child Support

Amount DUE each month

Amount Paid Last month

Life insurance

Amount DUE each month

Amount Paid Last month

Childcare/School Fees

Amount DUE each month

Amount Paid Last month

Life insurance

Amount DUE each month

Amount Paid Last month

Pet supplies

Amount DUE each month

Amount Paid Last month

Lawn care services

Amount DUE each month

Amount Paid Last month

Security system

Amount DUE each month

Amount Paid Last month

Household supplies

Amount DUE each month

Amount Paid Last month

Membership/subscription fees

Amount DUE each month

Amount Paid Last month

Entertainment (going out, movies, etc.)

Amount DUE each month

Amount Paid Last month

Totals

Total Amount DUE each month

Total Amount Paid Last month

Monthly Income

Type of Income

Estimated monthly net income (the amount after deductions/taxes) from this source

Required Documents

Please attach a lease or mortgage statement

Please attach your photo ID

Please attach proof of one month of income. This can be a check stub, bank statement for direct deposit food stamps, child support, alimony, etc.