Client Questionnaire (Page 3 of 4) in pdf

_____________________________________________________________________________________

Whose name is on the lease and/or on the Section 8 voucher: ______________________

If you are ever convicted of a sex offense, you may no longer be able to live within 1000 feet of a

school, even if you own your home.

Is your home within 1000 feet of a school: yes ⁪; no ⁪

PUBLIC BENEFITS

In many states, if you are convicted of a drug-related felony, you will be unable to receive public

assistance or food stamps for the rest of your life.

Do you receive public assistance (e.g. welfare, food stamps, SSI, etc.): yes ⁪; no ⁪

If yes, list the benefits you receive and how much you get: ________________________

________________________________________________________________________

Do you currently live, or plan to live, in a state other than North Carolina: yes ⁪; no ⁪

If yes, which state: ________________________________________________________

If you are applying for or receiving public assistance, you may be required to pass a national

warrant check. If you have an open felony warrant, in this case or any other cases, or if you are in

violation of a condition of probation or parole, you will be denied certain kinds of benefits,

including SSI, food stamps, welfare, and subsidized housing.

Do you have any open felony warrants: yes ⁪; no ⁪

DRIVER’S LICENSE

Certain drug and alcohol convictions can affect your ability to get or keep a driver’s license.

Do you have a driver’s license: yes ⁪; no ⁪

Do you need a driver’s license for your job: yes ⁪; no ⁪

STUDENT LOANS

In most cases, if you get a drug conviction while you are receiving student loans, your ability to get

student loans will be suspended for at least a year.

Are you currently attending college or trade school: yes ⁪; no ⁪

If yes, what school are you/will you attend, and what are you studying:

_______________________________________________________________________

Client Questionnaire Page 3