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TurnerImani HendersonGregg YoungerMariah SuttonAmon-ra SandersChris RandallAsia MaloneKobe E FugateJonathan r FrenchGregory L RutlandAntonio PerezAshley SandersQuenton PerkinsJames L ParkerAnthony Hon LamMelissa K. CantrellDouglas F BrownKenneth J. MortonDonte D. HarrisLindsey EspinozaVa'Monta HoltAntoine D. GarrisonJustin SniderEstwanasia M. JacksonRay W. donaldMatthew Joseph LageMelissa sword Melissa swordJeremiah FleurimondSabrea Faith VickersDeVarjay WilsonDonald W. EvansChristopher K. SmithMykel Ezra SmithHunter L HignightTerrell MortonJason Michael AleksaJasen AleksaTamita GreeneLaurie T. HarrisonDonald Dematrice DETHROWLavonte Jamel KeithHeather R LovanMarquan wilkinson Amir WilkinsonBrandon MannDottie AndrewsDevin AchenbachStephen DeWayne EtheridgeMahagony L SimmonsAdrian Garan MillerElijah Dewayne WilkinsKirsten Ashley PooleDoint'e StaplesLloyd D. PamKristina WillisJulian S. MuncieSeth GulleyJordan Paul RikerJordan RikerPatrick HorneIzayah HollandEltakus CookEltakus CookNicholas J. VanceJavon J. CushenberryJacqueline L. DavisShekinah O. DavisLuis M VargasBrian E. SeatsRichard JacksonAndrea M HarrisCory S. CritchfieldMichael J. PennymanTimothy J EtterThomas QuinnIsaiah C. HaywardAndre' J. StewartDavid A. JonesDavid QuintanaJason J. GardnerAli El-GhitTiffany PollomCody Allen WilliamsDominic A. SmithAndrea NeelyJayion SheltonAntwoine D WhiteAnthony HayesMaurice J. ThomasTina M. EdwardsIsaiah E. McDanielAnthony A. GriffieDawn M. HutchinsonGary M. LucasBreanna LoveJoshua Mark BurtonTimothy E. JohnsonJohn C. WilliamsCedrick D CarterKentrell D KendrickTiffany R. ColeAny Ann KindredYasmina BennettKeyon D. GillespieCahncey PayneChristopher R. BruceAmon-Ra SandersCassandra Maria-Kay WilkinsManuel AyonYour InformationName* First Middle Last Suffix* None Apply Jr Sr I II III IV Date of Birth* MM slash DD slash YYYY Age*Social Security Number Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*AdamsAllenBartholomewBentonBlackfordBooneBrownCarrollCassClarkClayClintonCrawfordDaviessDearbornDecaturDeKalbDelawareDuboisElkhartFayetteFloydFountainFranklinFultonGibsonGrantGreeneHamiltonHancockHarrisonHendricksHenryHowardHuntingtonJacksonJasperJayJeffersonJenningsJohnsonKnoxKosciuskoLaGrangeLakeLaPorteLawrenceMadisonMarionMarshallMartinMiamiMonroeMontgomeryMorganNewtonNobleOhioOrangeOwenParkePerryPikePorterPoseyPulaskiPutnamRandolphRipleyRushScottShelbySpencerSt. JosephStarkeSteubenSullivanSwitzerlandTippecanoeTiptonUnionVanderburghVermillionVigoWabashWarrenWarrickWashingtonWayneWellsWhiteWhitleyEmail Cell PhoneHome PhoneWork PhoneIncome Range* Under $10,000 $10,001 to $15,000 $15,001 to $20,000 $20,001 to $25,000 $25,001 to $30,000 $30,001 to $35,000 $35,001 to $40,000 $40,001 to $45,000 $45,001 to $50,000 $50,000 & up Gender* Female Transgender female Male Transgender male Non-binary Other Pronouns* She/Her/Hers He/Him/His They/Them/Theirs Race* African American/Black American Indian/Alaskan Native Asian Bi-racial Caucasian/White Hawaiian/Pacific Islander Multi-Racial Other Ethnicity* Hispanic Non-Hispanic Marital Status* Common Law Divorced Domestic Partnership Married, living separately Married, living together Separated Single (never married) Widowed Military Status* Active Duty Never Served Spouse of Active Duty Member Spouse of Veteran Veteran Primary Language* English Spanish Arabic Chinese Polish Other Emergency ContactName First Last Relationship* Spouse Son/daughter Parent Other relative Case worker Friend Other Phone* Supportive InformationPrimary Interest at Program Entry* Education/Training Digital Literacy/Computer Instruction Financial Education/Counseling Income Supports/Public Benefits Job Placement/Career Development Other Health Insurance Status* Insured through a government program No insurance at all Private insurance through a household member's employer Private insurance NOT through a household member's employer Highest Grade Completed* No High School Diploma GED/HSE High School Diploma Some College Associate’s Degree Bachelor’s Degree Master’s Degree Doctoral Degree Are you currently working?* Yes No Employment Status Part-time (less than 35 hours per week) Full-time (35 hours or more per week) Unemployed & seeking employment Not in the workforce (homemaker, retired, disabled) Other Is your current job also your longest job?* Yes No Was your previous job your longest job?* Yes No Vocational Training/Bridge Program History* No Vocational Training/Bridge Program History Some Vocational Training/Bridge Program(s) History Completed Vocational Training/Bridge Program(s) Are you in school or a training program?* Yes No Do you have a valid driver’s license?* Yes No Do you have a valid CDL driver’s license?* Yes No Do you have a valid chauffeur’s license?* Yes No In the past 12 months, number of full months worked*Please enter a number from 0 to 12.For the past 12 months, your earned income (after tax, this includes SS and disability):*For the past 12 months, your gross household income:*Do you receive SSI/SSDI?* Yes No Including yourself, how many people live in your household?*Please enter a number greater than or equal to 1. Do you have children ages 0 – 17?* Yes No How many children ages 0 – 17?*Please enter a number greater than or equal to 1.Child 1: Date of Birth* MM slash DD slash YYYY Child 2: Date of Birth* MM slash DD slash YYYY Child 3: Date of Birth* MM slash DD slash YYYY Child 4: Date of Birth* MM slash DD slash YYYY Child 5: Date of Birth* MM slash DD slash YYYY Child 6: Date of Birth* MM slash DD slash YYYY Child 7: Date of Birth* MM slash DD slash YYYY Child 8: Date of Birth* MM slash DD slash YYYY Child 9: Date of Birth* MM slash DD slash YYYY Do you have a relationship with your children?* Yes No Are you interested in improving or strengthening a relationship with your children?* Yes No Do you owe child support?* Yes No Do you currently pay child support?* Yes No Do you have a physical or mental disability?* Yes No Criminal Convictions* No Convictions Convicted of Felony/Felonies Convicted of Misdemeanor(s) only Don't know Select the level of your most recent felony conviction.* A B C D F 1 F 2 F 3 F 4 F 5 F 6 Are you on probation?* Yes No Are you on federal probation?* Yes No Are you on parole?* Yes No Are you on home detention?* Yes No Are you in a work release?* Yes No Officer or Case Manager Name First Last Officer or Case Manager Phone NumberDo you currently have charges pending?* Yes No In what county are your charges pending?* Boone Hamilton Hancock Hendricks Johnson Madison Marion Morgan Shelby Other When were you released from prison?* Never been to prison Currently incarcerated Less than 30 days 1 - 3 months 4 - 6 months 7 months - 1 year More than 1 - 3 years More than 3 - 5 years More than 5 - 10 years More than 10 years Which describes your current living situation?* House or apartment owned by you or a family member House or apartment rented by you or a family member – subsidized (Low income, Section 8 housing) Housing with work release, half-way house, recovery/sober living programs House or apartment rented by you or a family member – unsubsidized Household stays in a house or apartment for free Household is homeless (without a roof) or staying in a shelter What kind of assistance do you need?* Birth Certificate Employment Food or Clothing Housing Navigation Assistance State ID Transportation Free HIV Testing Substance Use Treatment/Support Financial Literacy/Budgeting Parenting Classes Mental Health Support/Treatment Educational Training Income Supports/Public Supports (SNAP, SSDI, etc) Peer Recovery Coaching MRT (Moral Reconation Therapy) Other What other assistance do you need?Do you need assistance with substance use?* Yes No Are you pre-release?* Yes No Are you currently incarcerated?* Yes No (i.e. Marion County Jail, VOA, Duvall, Craine House etc.)What is your expected release date?* MM slash DD slash YYYY