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  1. Fill out the Applicant’s FULL NAME.
  2. Fill out your current address (include zip code please).  If no address, please use a mailing address.
  3. Fill out how long you have lived at this address and a current phone or message number.
  4. Fill out previous address.
  5. Complete the Family Composition portion of the application beginning with the head of household. 

Example: 1.       Jane Doe              Head           30      02/02/69               1

Complete one line for each member of the household that will be on the HCV program, beginning with the head of household and working down to the youngest member of the household.

  1. Complete the marital status section of application.
  2. Complete the Social Security number blanks (must be completed to file your application).
  3. If employed, give employer’s name and address, amount of income and the family member who receives this income.
  4. Complete the Other Income section.
  5. Answer the questions at the bottom of the application.
  6. Provide copies of current picture ID, birth certificates and Social Security cards on all household members at the time of application completion – REQUIRED.


When you turn your application in, please fill out the date and time you turned it in and sign the application.  If you do not sign the application, your application will be delayed placement on the waiting list, it will be sent back to you for your signature.  Your application will be placed on the waiting list by date and time received.  The current waiting list is approximately 3 + years.  When your time comes up on the waiting list, you will be mailed a letter asking you to come in for an update.  At that time we will verify all information that we need in order to process your application.  If you move, you MUST let us know what your new address is.

Any questions regarding your application may be directed to the Applications Coordinators at
(910) 341-7727, ext 262 or 255.