Financial Responsibility

Name: Birthdate: Age:

Address: County:

City: State: Zip:

Parent / Legal Guardian — Name:

Address: City: State: Zip:

Home Phone: Work Phone:

Relationship:

( ) My parent/guardian will give me an allowance of $ per mo./wk.

( ) My parent/guardian has refused any financial support.

( ) Father/Mother employed? Approx. total monthly income?

I am on or will be applying for: County:

	Date Applied	Accepted	Rejected
Medical Assistance
TANF
WIC

I have been living ( ) at home ( ) own apartment ( ) other (please explain)

I understand that the Perry Center is funded by donations but they do not cover the total expense of operating. I also understand that each resident is required to pay some rent ($120 per month or $30 per week) depending on my situation.

At this time I agree to pay $ per month.

Resident:	Date:
Parent/Guardian:	Date:
Staff:	Date: