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Intake Form

Please be sure to complete this intake form prior to the start of your program. Be sure to contact your program coordinator if anything has changed. ONLY COMPLETE THIS FORM WHEN INSTRUCTED BY A MBCDC PROGRAM COORDINATOR. IF INTERESTED IN A MBCDC PROGRAM PLEASE FILL OUT THE INTEREST FORM LOCATED ON THE PROGRAM HOMEPAGE.

"*" indicates required fields

Step 1 of 4

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Today's Date

MM slash DD slash YYYY

Program Name

Community Education

Small Business

Community Maintenance

Home Repair

Name*

First Middle Name Last Suffix

Email*

Phone*

Preferred Method of Contact*

Email

Phone

Letter

Other

List other preferred method of contact

Address*

Street Address City State / Province / Region ZIP / Postal Code

Date of Birth*

Month

Day

Year

Gender*

Female

Male

Transgender Male

Transgender Female

Non-Binary

Other

Race*

African American/Black

American Indian/Alaskan Native

Asian

Bi-racial

Caucasian/White

Hawaiian/Pacific Islander

Multi-Racial

Other

Marital Status*

Common Law

Single (never married)

Married living together

Married living separately

Widowed

Separated

Divorced

Domestic Partner

Ethnicity*

Hispanic

Non-Hispanic

Disability*

Yes

No

Are you a Military Veteran?*

Active Duty

Veteran

Spouse of Active Duty Member

Spouse of Veteran

Never Served

Criminal Convictions*

No Convictions

Convicted of Felony(ies)

Convicted of Misdemeanor(s)

Don't Know

Highest Level of Education?*

No High School Dipolma

GED

High School Diploma

Technical Certificate

Some College

AA Degree

Bachelors Degree

Masters Degree

Doctoral Degree

Employment*

Employed Part-time (Less than 35 hrs per week)

Employed Full-time (35 hrs or more per week)

Unemployed (seeking employment)

Not in the workforce (homemaker, disabled, retired)

Other

For the 12 mos, your Gross Household Income*

Income Source*

Social Security

Pension/ Annuity

Interest/ Dividends

Earned Income from job(s)

Disability

Child Support

Other

What is your credit score?*

What is your household size?*

Number of people including yourself.

Household Members Names, Relationship, Birthday, Education, & Employment Status*

MBCDC Programs

Program Interest*

Please check all that apply.

Community Education

Community Maintenance

Employment Services (25-35 years old)

Financial Education

Homeownership

Homeowner Repair

Individual Development Account (Savings Program)

Small Business

Volunteer

YES - Youth Employment Services (16-24)

Other

Jumpstart

List Other Program Interest Below (Program name)*

Small Business

Business Name*

What type of business do you operate?*

Annual Business Revenue*

How many employees - including yourself*

Business Registered with Secretary of State?

Yes

No

Unsure

Certified women/minority/veteran/disable-owned?

Yes

No

Unsure

Do you have insurance?

Yes

No

Are you bonded?

Yes

No

Do you have a business license?

Yes

No

N/A

Additional Information

Jumpstart

Affiliation

First Choice

Second Choice

Third Choice

Home Repair

How many years have you owned your home?*

Have you received FHLBI grant funds in the past 5 years?*

Yes

No

I don't know

Have you applied for FHLBI funds at another agency?*

Yes

No

I don't know

Are your mortgage payments current?*

Yes

No

I don't know

Do you have homeowners insurance?*

Yes

No

I don't know

Are your property taxes paid and current?*

Yes

No

I don't know

Is there anyone on the DEED of the home that is not living in the home?*

Yes

No

I don't know

If yes, what is their relationship to you?*

Community Maintenance

Services Needed

Gutter Cleaning

Lawn Care

Leaf Removal

Window Cleaning

Trash Removal

Paint

Pest Control*

Other

Other

How did you hear about us?

Word of Mouth

Social Media

Event

Search Engine

Recommended

Other

I hereby transfer and grant the Martindale Brightwood Community Development Corporation ("MBCDC") the exclusive right to use and authorize others to use all or any part of my (his/her) interview/photograph/video in related media such as books, newsletters, flyers, magazines, journals, pamphlets, electronic (Internet) and other written and video formats. I also hereby release MBCDC and its directors, members, trustees, officers, employees, and agents from any and all claims, demands, causes of action and suites, including but not limited to, claims for invasion of privacy, defamation, breach of contract or other breach of duty arising out of of in connection with the use of this interview, photo, or video.*

Agree

I hereby certify that the information included on this form is correct to the best of my knowledge and that such information may be subject to verification by representatives of Martindale Brightwood CDC for purposes of meeting requirements for a program.*

Agree

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2435 North Sherman Drive, Suite 4, Indianapolis, IN 46218

(317) 924-8042

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