Verification Questionnaire Name*Address* Street Address Address Line 2 City State / Province / Region Phone Number*Voice Mail*YesNoHave you received help from MNIN before?*YesNoIf Yes - What did you get help with?*If you have gotten help, have you "Paid it Forward"?*YesNoHow?*Please list your most important need (We help with one need at a time)*If you are asking for furniture, what are you currently using?How long have you lived at your current residence?*Are you a veteran?*YesNoAre you 55 years of age or older?*YesNoIf you have children that live in the home, how many and what ages are the children?What is the number of adults living in the home? Please list names.*Are you working/seeking work?*Full-timePart-timeUnemployedMonthly IncomeAre you disabled?*YesNoDo you receive any disability financial assistance or other assistance?*YesNoHow Much?*Social Security DisabilitySocial SecurityVA DisabilityFood StampsTANFFUnemploymentChild SupportOther16. Do you receive any other government assistance such as housing allowances including Section 8, or other low income housing?*YesNoWhat is your monthly housing payment?*Have you asked for assistance from other organizations such as 0pps Inc? Salvation Army Family Services? ST. Vincent DePaul, Etc.?*YesNoIf you have received help from other organizations, what did you receive?If you were turned down, Why?Have you asked your friends or family for help?Please give us a brief description of your circumstances*