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CARES T.E.A.M. Services Request

2. Norfolk CARES T.E.A.M. Services Request

4. First Name*

5. Last Name*

7. Date of Birth
   Date of Birth

   please enter the mm/dd/yyyy for your date of birth.

8. Email address:

9. Telephone number

11. Address1

13. City

14. State

15. Zip

17. Are you currently receiving SNAP benefits?*

    1. Yes
    2. No

19. Do you have any children 0-18 years old on your SNAP case?*

    1. Yes
    2. No
    3. N/A

    If you do not receive SNAP benefits, please select N/A

21. Are you currently receiving TANF benefits?*

    1. Yes
    2. No

23. Do you currently Live in the City of Norfolk?*

    1. Yes
    2. No

25. Have you ever been convicted of a misdemeanor or felony charge*

    1. Yes
    2. No

27. Are you a youth or young adult (age 17-27) who is transitioning out of foster care? *

    1. Yes
    2. No

29. Are you a non-custodial parent with a Department of Child Support Enforcement case with TANF debt?*

    1. Yes
    2. No

31. Are you between the age of 18-49 years old?*

    1. Yes
    2. No

33. Additional comments

35. How did you hear about us?

Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field