100 Neediest Case Story Form
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3100 Neediest CASE STORY FORM 2015 – DUE FRIDAY, SEPTEMBER 25, 2015
Agency #00566
Agency Name St. Louis Public Schools
Student Information
First Name ___________________________ Last Name _______________________________
Address _______________________________________________________________________
Street
City
State
Zip
Parent Information
First Name ___________________________ Last Name _______________________________
Parent Gender _______ Telephone Number ____________________________
Disability/Chronic Medical Condition ___________________ Detail _______________________
Family Population: Men ____ Women ____ Children (under 18) ____
Disburse check funds to: Client ____ Other Agency or Person ____________________________
Financial Status (List Monthly Dollar Amount)
Foster Care $______ Food Stamps $______ Unemployment $______TANF $______ SSI $______
Social Security $______ Work Full Time $ ______ Work Part Time $______ Child Support $____
Other (include description) $_____________________________________________________
Living Status
Homeless _______ Living with Relatives _______ Public Housing _______ Section 8 _______
Independent Living Program _______ Transitional Housing _______ Other _______________
Expenses (List Monthly Dollar Amount)
Child Support $______ Gas $______ Electric $______ Medical $______ Phone $______
Transportation $______ Minor Child Expenses $______ Rent/House Payment $______
Other (include description) $_____________________________________________________
Needs
Bicycle__Dryer(Gas)__Dryer(Electric)__Eye Glasses __Beds, Twin __Queen __Tables__Chairs__
Dressers__Washer__Clothing__Home Repair__Car Repair__Medical Bills__Refrigerator__
Utility Payment__Stove(Gas)__Stove(Electric)__House Payment/Rent__Wheelchair__
STLCC Tuition__Transportation__Phone__Gift Cards (Target__Walmart__Gas__Furniture__)
Additional comments____________________________________________________________
_____________________________________________________________________________
Family: List relationship to the client: Child, Extended Family, Foster Parent, Grandchild,
Grandparent, Non-relative, Parent Sibling, or Spouse. If case is not being adopted (Level 1)
clothing sizes are not necessary.
Name
Relationship to client
Sex
Age
Clothing Sizes
Pants/shirts/shoes
1.____________________________________________________________________________
2.____________________________________________________________________________
3.____________________________________________________________________________
4.____________________________________________________________________________
5.____________________________________________________________________________
6.____________________________________________________________________________
7.____________________________________________________________________________
8.____________________________________________________________________________
9.____________________________________________________________________________
10.___________________________________________________________________________
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Parent category: Business