First Name:Last Name or Client ID: Street Address:City: State:Zip Code:Phone Number(Optional): Email Address:Date of Birth:// (Optional) 1. Race and Ethnicity Which best describes your race/ethnicity?(Mark ALLcheck boxes that apply) Indigenous American Indian/Native American (Specific Group:) Indigenous from Mexico, the Caribbean, Central America or South America (Specific Group: )Other Indigenous AsianChineseFilipinoJapaneseKoreanMongolian Central Asian South Asian Southeast Asian Other Asian Latino Caribbean Central American Mexican South American Black African African American Caribbean, Central American, South American or MexicanOther Black Middle Eastern/West Asian or North African North African West Asian Other Middle Eastern or North African Pacific Islander Chamorro Native Hawaiian Samoan Other Pacific Islander 2. Gender Identity and Sexual Orientation What is your gender? (Mark the ONEthat best describes your current gender identity) Fema le Male Genderqueer/Gender Non- BinaryTrans Female Trans Male How do you describe your sexual orientation or sexualidentity?(Mark ONE) Bisexual Gay/Lesbian/Same-Gender LovingQuestioning/Unsure Straight/Heterosexual Not Listed. Please Specify: Declineto Answer By what name do you wish to be called? (Optional) Mayor's Office of Housing & CommunityDevelopment (MOHCD) MOHCD Client Intake Form Review this form with client and complete all items Refer to the instruction sheet to help with form completion 3.Keep on file for five years Fiscal Year 2023- 24
3. Language What is your primary language spoken at home? (Mark ONE) Chinese - CantoneseRussian Chinese - MandarinSpanish EnglishVietnamese FilipinoOther Language. Please Specify: What gender pronouns do you use? [Optional] (Mark ONE) She/Her/HersThey/Them/Theirs He/Him/HisNot Listed. Please Specify: 4.Veteran and Disability Status _________________________________________________________________________________________________ Are you a veteran?YesNo Are you a person with a disability?YesNo 5.Family Size and Income 6.Income Certification I hereby certify that, to the best of my knowledge, the above statements are true and correct. I understand this information is subject toverification only by authorized U.S. Department of Housing & Urban Development (HUD) officials for federally-funded grants. CLIENTINTERVIEWER Client Printed NameInterviewer Printed Name Parent/Client SignatureDateInterviewer SignatureDateWhich best describes your family?A familyincludes a singleperson or a group of people living together. (Mark ONE) Single Headed Family Dual Headed Family Number of persons living in your family (including yourself): Estimated income for next 12 months for all adult members: $ Do you receive any type of publicbenefits assistance?(Mark ALL that apply)CalWorks CalFresh Cash Assistance Linked to Medi-Cal (CALM) Cash Assistance Program for Immigrants (CAPI) County Adult Assistance Program (CAAP) Medi-Cal Refugee Cash Assistance Social Security Disability Insurance (SSDI) Supplemental Security Income (SSI) What source(s) of information were used to verify your income?(Mark ALL that apply) Public Benefits(mark here if you chose any option to the left) Payroll Stub Tax Return Unemployment Benefits Veteran's Benefits Rental Assistance(e.g., Section 8 voucher) Placed in Foster Care Self-Certified. Please explain:
MOHCD collects data on race, ethnicity, sexual orientation and gender identity, in order to ensure the programs and services we fund are addressing the needs of the vulnerable communities we serve, and to report anonymous information to key funders like HUD. MOHCD protects your personally identifiable information (PII) from loss, theft, misuse and unauthorized access and disclosure. PII includes your name, address, birthdate, race and ethnicity, gender, sexual orientation/identify, and household size and income. Also, PII is never included in reports, public documents or public websites, and can only be seen by authorized persons when it's necessary to achieve the purposes noted above.