Sandy Oaks Citizen Request Form

This form has been created as a means for citizens to identify needs they may have, or to submit on behalf of their neighbor. These questions are a means to identify where assistance may be needed while protecting the privacy of those requiring assistance.

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Introduction

Use this form to submit a request for assistance. This could be for a variety of reasons, and in the interest of protecting your privacy, we will not ask you to identify your needs on this form. At the bottom of the form is a question regarding your consent to be contacted by a city representative. If you do not consent, you will not be contacted. If you consent to be contacted, your needs can be discussed at that time.
Are you submitting for yourself or a neighbor?*
The name of the individual making submission
Are you needing assistance and/or are you signing up to volunteer? (check all that apply)
The following questions are specific to the household address for the resident being submitted.
Name of neighbor the form is being submitted for (yourself or neighbor). Only one submission is needed per household.
Date of Birth of neighbor the form is being submitted for (yourself or neighbor). Only one submission is needed per household.
Enter the address for the name being submitted above.
Please provide the phone number of the person who should be contacted.
What is the resident's relationship status
What is the total annual income for the household?
How many in the household are aged 0-3?
How many in the household are aged 4-5?
How many in the household are aged 6-12?
How many in the household are aged 13-17?
How many in the household are aged 18-30?
How many in the household are aged 31-55?
How many in the household are aged 55-60?
How many in the household are aged 60 or older?

Monthly Income Sources

Monthly income from employment
Monthly income from unemployment
Monthly income from SSI
Montly value of TANF received
Monthly income from Social Security
Monthly amount of child support
Do you have any physical limitations that prevent you from leaving the home to obtain necessary supplies?*
Does anyone in your household have available transportation?
Are you available to assist with other neighbors?
Do you consent to being contacted by a representative from the City of Sandy Oaks?*
Preferred Method of Contact

NOTICE: It is illegal to forge a government document and persons may be criminally prosecuted.

DISCLAIMER: Under the Texas Public Information Act, Chapter 552 of the Government Code (the “Act”), “public information” is information written, produced, collected, assembled, or maintained under a law or ordinance or in connection with the transaction of official business by a governmental body, such as the City of Sandy Oaks. While the Act provides for exceptions from disclosure of information, the City cannot guarantee or assure that information provided in response to this form is confidential and/or excepted from disclosure under the Act, and therefore any information submitted in response to this form may be considered public information under the Act and released to person(s) requesting such information.

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