PATH Assistance Intake Form | PLAN TO ACCOMODATE TRAVEL HOME P.A.T.H.

Minnesota USA

+1 (612) 208-6739

Info@pathfoundationinc.org

Plan to Accommodate Travel Home - Foundation (PATH) is a federally recognized 501(c)(3) nonprofit organization. Contributions may be tax-deductible as permitted by law.

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Date and time of Form

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Thank you for contacting PATH Foundation. Please complete the form below. Submission of this form does not guarantee assistance. A PATH representative will review your request and contact you regarding available resources and eligibility.

First name*

Last name*

Address*

Phone

Birthday

Month

Day

Year

Is this an emergency?

Yes

Do you currently have reliable transportation?

Yes

What language do you prefer to communicate in?

English

French

Spanish

Arabic

Somali

Other

Current Housing Status

Renting

Own Home

Staying with Family/Friends

Shelter

Hotel/Motel

Unsheltered/Homeless

Other

Household Information

Number of Adults

Number of Children

Employment Status

Employed Full-Time

Employed Part-Time

Self-Employed

Unemployed

Retired

Student

Other

Please describe your current situation and how PATH Foundation may assist you.

What type of assistance are you seeking today? (Check all that apply)

Food Assistance

Housing Assistance

Temporary Lodging

Utility Assistance

Transportation Assistance

Immigration Referral

Counseling & Emotional Support

Resource Navigation

Repatriation Planning

Reintegration Support

Other

Do you have food available for the next 72 hours?

Yes

Do have an eviction notice?

Yes

Court date?

Amount owed?*

Food Needs

Yes

House Size

Dietary restrictions?

Immigration Impact

Would you like a referral to an immigration attorney or legal service provider?

Yes

Explain Briefly*

Monthly Household Income*

Amount of Rent Owed

Best Time to Contact You

Emergency Contact Name

Emergency Contact Phone Number

How did you hear about PATH Foundation?

211

Friend/Family

Church

Social Media

Website

Community Organization

Other

If you were referred by 211, please provide your referral number (if available):

File upload/Document Upload

Single choice*

I authorize PATH Foundation to contact me by phone, email, text message, or mail regarding my request for assistance.

Signature

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I certify that the information provided is true and accurate.

I understand that submission does not guarantee assistance.

PATH Foundation reviews all requests individually. Submission of this application does not guarantee financial assistance, housing support, food assistance, transportation assistance, or any other service. Assistance is subject to eligibility requirements

Check

Additional Community Resources

While PATH Foundation continues to develop its assistance programs and seek funding, you may wish to explore the following Minnesota resources that may be able to provide more immediate assistance:

• Minnesota Housing – RentHelpMN Resources

https://www.mnhousing.gov/rental-housing/renters/resources-for-renters.html

• United Way 211

Dial 211 or visit

https://www.211unitedway.org

for referrals to emergency rent assistance programs and community resources.

• Community Action Partnership of Hennepin County

https://cap-hc.org

• HOME Line Tenant Hotline

Phone: 612-728-5767

Website: https://homelinemn.org

I understand that submitting this request does not guarantee assistance and that any assistance provided by PATH Foundation is subject to available funding, program eligibility, and approval criteria.

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