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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 17-24) 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