{"id":16,"date":"2020-05-07T23:56:58","date_gmt":"2020-05-07T23:56:58","guid":{"rendered":"http:\/\/ghhcrf.com\/blog\/home\/"},"modified":"2020-05-11T01:28:51","modified_gmt":"2020-05-11T01:28:51","slug":"home","status":"publish","type":"page","link":"http:\/\/ghhcrf.com\/blog\/","title":{"rendered":"Client Request Form"},"content":{"rendered":"\n<div id=\"erf_form_container_47\" class=\"erf-container erf-contact erf-label-top erf-layout-one-column erf-style-rounded-corner\">\n        \n    \n         \n                    <div class=\"erf-content-above\">\n                Contact us by filling out the form below.            <\/div>\n            <form method=\"post\" enctype=\"multipart\/form-data\" class=\"erf-form erf-front-form\" data-parsley-validate=\"\" novalidate=\"true\" data-erf-submission-id=\"0\" data-erf-form-id=\"47\">\n                <div class=\"erf-form-html\" id=\"erf_form_47\">\n                    <div class=\"rendered-form\">\n                        <div class=\"erf-richtext erf-element-width-12\"><div data-non-input='1' data-ref-label='ref-f99cThXJ' data-ref-id='ref-FxAZfBZc' class='erf-rich-text' ><ul>\n<li>We need at least one telephone number to be able to contact you before we can process your application.<\/li>\n<li>Please be prepared to give us your social security number when we contact you by phone.<\/li>\n<li>Items marked with * are required.<\/li>\n<\/ul><\/div><\/div><div class=\"erf-header erf-element-width-12\"><h4  data-non-input='1' data-ref-label='ref-mC8FJuzW' data-ref-id='ref-mqipj3ZX' class='' >God's Helping Hands - Client Request Form<\/h4><\/div><div class=\"erf-text form-group field-text-171415689162 erf-element-width-12\"><label for=\"text-171415689162\" class=\"erf-text-label\">First Name<span class=\"erf-required\">*<\/span><\/label><input type='text' maxlength='50' required='required' class='form-control' name='text-171415689162' id='text-171415689162'  \/><\/div><div class=\"erf-text form-group field-field-mIWfmCvfGSXaWr7 erf-element-width-12\"><label for=\"field-mIWfmCvfGSXaWr7\" class=\"erf-text-label\">Middle Name<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-mIWfmCvfGSXaWr7' required='required' id='field-mIWfmCvfGSXaWr7'  \/><\/div><div class=\"erf-text form-group field-field-zmOtXrvQ0tW2ucl erf-element-width-12\"><label for=\"field-zmOtXrvQ0tW2ucl\" class=\"erf-text-label\">Last Name<span class=\"erf-required\">*<\/span><\/label><input type='text' required='required' maxlength='50' class='form-control' name='field-zmOtXrvQ0tW2ucl' id='field-zmOtXrvQ0tW2ucl'  \/><\/div><div class=\"erf-email form-group field-text-818888510 erf-element-width-12\"><label for=\"text-818888510\" class=\"erf-email-label\">Email<span class=\"erf-required\">*<\/span><\/label><input type='email' required='required' class='form-control' name='text-818888510' id='text-818888510'  \/><\/div><div class=\"erf-text form-group field-field-v9JUjMO17hfa2th erf-element-width-12\"><label for=\"field-v9JUjMO17hfa2th\" class=\"erf-text-label\">Date of Birth<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-v9JUjMO17hfa2th' placeholder='mm\/dd\/yyyy' required='required' id='field-v9JUjMO17hfa2th'  \/><\/div><div class=\"erf-text form-group field-field-2e8pfQaiuZM5A4m erf-element-width-12\"><label for=\"field-2e8pfQaiuZM5A4m\" class=\"erf-text-label\">Age<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-2e8pfQaiuZM5A4m' maxlength='3' required='required' id='field-2e8pfQaiuZM5A4m'  \/><\/div><div class=\"erf-text form-group field-field-6P70CCj3htrbgKJ erf-element-width-12\"><label for=\"field-6P70CCj3htrbgKJ\" class=\"erf-text-label\">Gender<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-6P70CCj3htrbgKJ' required='required' id='field-6P70CCj3htrbgKJ'  \/><\/div><div class=\"erf-text form-group field-field-LDlLyCzUqK8FHaT erf-element-width-12\"><label for=\"field-LDlLyCzUqK8FHaT\" class=\"erf-text-label\">Marital Status<span class=\"erf-required\">*<\/span><span class=\"tooltip-element\" tooltip=\"Never Married Married Separated Divorced Widowed\"><i class=\"fa fa-info\" aria-hidden=\"true\"><\/i><\/span><\/label><input type='text' class='form-control' name='field-LDlLyCzUqK8FHaT' required='required' id='field-LDlLyCzUqK8FHaT'  \/><\/div><div class=\"erf-street1 form-group field-field-bWNNHWM9Vfj9XMR erf-element-width-12\"><label for=\"field-bWNNHWM9Vfj9XMR\" class=\"erf-street1-label\">Street Address<span class=\"erf-required\">*<\/span><\/label><input type='street1' class='form-control' name='field-bWNNHWM9Vfj9XMR' required='required' id='field-bWNNHWM9Vfj9XMR'  \/><\/div><div class=\"erf-street2 form-group field-field-PqIIACKJCezmr5U erf-element-width-12\"><label for=\"field-PqIIACKJCezmr5U\" class=\"erf-street2-label\">Lot or Apartment<\/label><input type='street2' class='form-control' name='field-PqIIACKJCezmr5U' id='field-PqIIACKJCezmr5U'  \/><\/div><div class=\"erf-city form-group field-field-weggroiM4KZEq7s erf-element-width-12\"><label for=\"field-weggroiM4KZEq7s\" class=\"erf-city-label\">City<span class=\"erf-required\">*<\/span><\/label><input type='city' class='form-control' name='field-weggroiM4KZEq7s' required='required' id='field-weggroiM4KZEq7s'  \/><\/div><div class=\"erf-zip form-group field-field-E1VGRjsxtice9PA erf-element-width-12\"><label for=\"field-E1VGRjsxtice9PA\" class=\"erf-zip-label\">Zip<span class=\"erf-required\">*<\/span><\/label><input type='zip' class='form-control' name='field-E1VGRjsxtice9PA' required='required' id='field-E1VGRjsxtice9PA'  \/><\/div><div class=\"erf-text form-group field-field-NZ6GFARgREkNosF erf-element-width-12\"><label for=\"field-NZ6GFARgREkNosF\" class=\"erf-text-label\">State<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-NZ6GFARgREkNosF' required='required' id='field-NZ6GFARgREkNosF'  \/><\/div><div class=\"erf-city form-group field-field-qp7WJDiEzlvrsQO erf-element-width-12\"><label for=\"field-qp7WJDiEzlvrsQO\" class=\"erf-city-label\">County<span class=\"erf-required\">*<\/span><\/label><input type='city' class='form-control' name='field-qp7WJDiEzlvrsQO' required='required' id='field-qp7WJDiEzlvrsQO'  \/><\/div><div class=\"erf-tel form-group field-field-WhKMA8q47AScVUZ erf-element-width-12\"><label for=\"field-WhKMA8q47AScVUZ\" class=\"erf-tel-label\">Main Contact Phone<span class=\"erf-required\">*<\/span><\/label><input type='tel' class='form-control' name='field-WhKMA8q47AScVUZ' required='required' enable-intl='1' id='field-WhKMA8q47AScVUZ'  \/><\/div><div class=\"erf-tel form-group field-field-ljh96gGdC18WkFA erf-element-width-12\"><label for=\"field-ljh96gGdC18WkFA\" class=\"erf-tel-label\">Home Phone<\/label><input type='tel' class='form-control' name='field-ljh96gGdC18WkFA' enable-intl='1' id='field-ljh96gGdC18WkFA'  \/><\/div><div class=\"erf-tel form-group field-field-aOdrMubPukgZ1DC erf-element-width-12\"><label for=\"field-aOdrMubPukgZ1DC\" class=\"erf-tel-label\">Work Phone<\/label><input type='tel' class='form-control' name='field-aOdrMubPukgZ1DC' enable-intl='1' id='field-aOdrMubPukgZ1DC'  \/><\/div><div class=\"erf-text form-group field-field-4r1GDfakdIcPRFT erf-element-width-12\"><label for=\"field-4r1GDfakdIcPRFT\" class=\"erf-text-label\">Employed<span class=\"erf-required\">*<\/span><span class=\"tooltip-element\" tooltip=\"Yes No\"><i class=\"fa fa-info\" aria-hidden=\"true\"><\/i><\/span><\/label><input type='text' class='form-control' name='field-4r1GDfakdIcPRFT' required='required' id='field-4r1GDfakdIcPRFT'  \/><\/div><div class=\"erf-text form-group field-field-0ruPELZHOMfMbxH erf-element-width-12\"><label for=\"field-0ruPELZHOMfMbxH\" class=\"erf-text-label\">Where Employed<\/label><input type='text' class='form-control' name='field-0ruPELZHOMfMbxH' id='field-0ruPELZHOMfMbxH'  \/><\/div><div class=\"erf-header erf-element-width-12\"><h4  data-non-input='1' data-ref-label='ref-jJlJXp7f' data-ref-id='ref-YWORDvUv' class='' >Information on Spouse\/Adult in Home<\/h4><\/div><div class=\"erf-text form-group field-field-yzuyCaFung3wLQk erf-element-width-12\"><label for=\"field-yzuyCaFung3wLQk\" class=\"erf-text-label\">First Name<\/label><input type='text' maxlength='50' class='form-control' name='field-yzuyCaFung3wLQk' id='field-yzuyCaFung3wLQk'  \/><\/div><div class=\"erf-text form-group field-field-XTFmkCDx0DRcNwg erf-element-width-12\"><label for=\"field-XTFmkCDx0DRcNwg\" class=\"erf-text-label\">Middle Name<\/label><input type='text' class='form-control' name='field-XTFmkCDx0DRcNwg' id='field-XTFmkCDx0DRcNwg'  \/><\/div><div class=\"erf-text form-group field-text-258948804225 erf-element-width-12\"><label for=\"text-258948804225\" class=\"erf-text-label\">Last Name<\/label><input type='text' maxlength='50' class='form-control' name='text-258948804225' id='text-258948804225'  \/><\/div><div class=\"erf-text form-group field-field-nQb1umtT9yeh4I2 erf-element-width-12\"><label for=\"field-nQb1umtT9yeh4I2\" class=\"erf-text-label\">Date of Birth<\/label><input type='text' class='form-control' name='field-nQb1umtT9yeh4I2' placeholder='mm\/dd\/yyyy' id='field-nQb1umtT9yeh4I2'  \/><\/div><div class=\"erf-text form-group field-field-twHEzLFMjDG9XCp erf-element-width-12\"><label for=\"field-twHEzLFMjDG9XCp\" class=\"erf-text-label\">Age<\/label><input type='text' class='form-control' name='field-twHEzLFMjDG9XCp' maxlength='3' id='field-twHEzLFMjDG9XCp'  \/><\/div><div class=\"erf-text form-group field-field-oOcuqKxPOUAn0hl erf-element-width-12\"><label for=\"field-oOcuqKxPOUAn0hl\" class=\"erf-text-label\">Gender<\/label><input type='text' class='form-control' name='field-oOcuqKxPOUAn0hl' id='field-oOcuqKxPOUAn0hl'  \/><\/div><div class=\"erf-text form-group field-field-EXHPKUObSqT5M0C erf-element-width-12\"><label for=\"field-EXHPKUObSqT5M0C\" class=\"erf-text-label\">Marital Status<span class=\"tooltip-element\" tooltip=\"Never Married Married Separated Divorced Widowed\"><i class=\"fa fa-info\" aria-hidden=\"true\"><\/i><\/span><\/label><input type='text' class='form-control' name='field-EXHPKUObSqT5M0C' id='field-EXHPKUObSqT5M0C'  \/><\/div><div class=\"erf-street1 form-group field-field-7xc18CypszUTCgs erf-element-width-12\"><label for=\"field-7xc18CypszUTCgs\" class=\"erf-street1-label\">Street Address<\/label><input type='street1' class='form-control' name='field-7xc18CypszUTCgs' id='field-7xc18CypszUTCgs'  \/><\/div><div class=\"erf-street2 form-group field-field-324sjB3COOStlYt erf-element-width-12\"><label for=\"field-324sjB3COOStlYt\" class=\"erf-street2-label\">Lot or Apartment<\/label><input type='street2' class='form-control' name='field-324sjB3COOStlYt' id='field-324sjB3COOStlYt'  \/><\/div><div class=\"erf-city form-group field-field-tItdHUz9Z6qyOdw erf-element-width-12\"><label for=\"field-tItdHUz9Z6qyOdw\" class=\"erf-city-label\">City<\/label><input type='city' class='form-control' name='field-tItdHUz9Z6qyOdw' id='field-tItdHUz9Z6qyOdw'  \/><\/div><div class=\"erf-text form-group field-field-1rOfa76oxU3tmcO erf-element-width-12\"><label for=\"field-1rOfa76oxU3tmcO\" class=\"erf-text-label\">State<\/label><input type='text' class='form-control' name='field-1rOfa76oxU3tmcO' id='field-1rOfa76oxU3tmcO'  \/><\/div><div class=\"erf-zip form-group field-field-5aEb5IzS8Zp2QIw erf-element-width-12\"><label for=\"field-5aEb5IzS8Zp2QIw\" class=\"erf-zip-label\">Zip<\/label><input type='zip' class='form-control' name='field-5aEb5IzS8Zp2QIw' id='field-5aEb5IzS8Zp2QIw'  \/><\/div><div class=\"erf-city form-group field-field-DHT5qsfozhwv64x erf-element-width-12\"><label for=\"field-DHT5qsfozhwv64x\" class=\"erf-city-label\">County<\/label><input type='city' class='form-control' name='field-DHT5qsfozhwv64x' id='field-DHT5qsfozhwv64x'  \/><\/div><div class=\"erf-tel form-group field-field-jYrRc9CQo48mAK1 erf-element-width-12\"><label for=\"field-jYrRc9CQo48mAK1\" class=\"erf-tel-label\">Home Phone<\/label><input type='tel' class='form-control' name='field-jYrRc9CQo48mAK1' enable-intl='1' id='field-jYrRc9CQo48mAK1'  \/><\/div><div class=\"erf-tel form-group field-field-1BocZQbMxUuT12N erf-element-width-12\"><label for=\"field-1BocZQbMxUuT12N\" class=\"erf-tel-label\">Work Phone<\/label><input type='tel' class='form-control' name='field-1BocZQbMxUuT12N' enable-intl='1' id='field-1BocZQbMxUuT12N'  \/><\/div><div class=\"erf-tel form-group field-field-2fochnESRve515h erf-element-width-12\"><label for=\"field-2fochnESRve515h\" class=\"erf-tel-label\">Other Phone<\/label><input type='tel' class='form-control' name='field-2fochnESRve515h' enable-intl='1' id='field-2fochnESRve515h'  \/><\/div><div class=\"erf-text form-group field-field-dPJITCL5KgmwbTH erf-element-width-12\"><label for=\"field-dPJITCL5KgmwbTH\" class=\"erf-text-label\">Employed<span class=\"tooltip-element\" tooltip=\"Yes No\"><i class=\"fa fa-info\" aria-hidden=\"true\"><\/i><\/span><\/label><input type='text' class='form-control' name='field-dPJITCL5KgmwbTH' id='field-dPJITCL5KgmwbTH'  \/><\/div><div class=\"erf-text form-group field-field-Dabi4PDwlZEdmOQ erf-element-width-12\"><label for=\"field-Dabi4PDwlZEdmOQ\" class=\"erf-text-label\">Where Employed<\/label><input type='text' class='form-control' name='field-Dabi4PDwlZEdmOQ' id='field-Dabi4PDwlZEdmOQ'  \/><\/div><div class=\"erf-header erf-element-width-12\"><h4  data-non-input='1' data-ref-label='ref-pVqirZoU' data-ref-id='ref-Yj1COhR4' class='' >Children\/Others Living in Home<\/h4><\/div><div class=\"erf-text form-group field-field-5nLhdtRjhzaFdv7 erf-element-width-4\"><label for=\"field-5nLhdtRjhzaFdv7\" class=\"erf-text-label\">Number of Adults in Home<\/label><input type='text' class='form-control' name='field-5nLhdtRjhzaFdv7' id='field-5nLhdtRjhzaFdv7'  \/><\/div><div class=\"erf-text form-group field-field-ZxgAljHakSeG0l7 erf-element-width-4\"><label for=\"field-ZxgAljHakSeG0l7\" class=\"erf-text-label\">Number of Children in Home<\/label><input type='text' class='form-control' name='field-ZxgAljHakSeG0l7' id='field-ZxgAljHakSeG0l7'  \/><\/div><div class=\"erf-text form-group field-field-wDKjwt0jtp9o7mx erf-element-width-4\"><label for=\"field-wDKjwt0jtp9o7mx\" class=\"erf-text-label\">Total Living in Home<\/label><input type='text' class='form-control' name='field-wDKjwt0jtp9o7mx' id='field-wDKjwt0jtp9o7mx'  \/><\/div><div class=\"erf-text form-group field-field-DJhpNH8WZNEJF94 erf-element-width-12\"><label for=\"field-DJhpNH8WZNEJF94\" class=\"erf-text-label\">Full Name and Age<\/label><input type='text' class='form-control' name='field-DJhpNH8WZNEJF94' id='field-DJhpNH8WZNEJF94'  \/><\/div><div class=\"erf-text form-group field-field-aZsWjgqAXpwvJdA erf-element-width-12\"><label for=\"field-aZsWjgqAXpwvJdA\" class=\"erf-text-label\">Full Name and Age<\/label><input type='text' class='form-control' name='field-aZsWjgqAXpwvJdA' id='field-aZsWjgqAXpwvJdA'  \/><\/div><div class=\"erf-text form-group field-field-jxVPe2qVeJgskbd erf-element-width-12\"><label for=\"field-jxVPe2qVeJgskbd\" class=\"erf-text-label\">Full Name and Age<\/label><input type='text' class='form-control' name='field-jxVPe2qVeJgskbd' id='field-jxVPe2qVeJgskbd'  \/><\/div><div class=\"erf-text form-group field-field-PLbVQ2DcQxqzbBM erf-element-width-12\"><label for=\"field-PLbVQ2DcQxqzbBM\" class=\"erf-text-label\">Full Name and Age<\/label><input type='text' class='form-control' name='field-PLbVQ2DcQxqzbBM' id='field-PLbVQ2DcQxqzbBM'  \/><\/div><div class=\"erf-text form-group field-field-1sTj5N9sFvU3UNQ erf-element-width-12\"><label for=\"field-1sTj5N9sFvU3UNQ\" class=\"erf-text-label\">Full Name and Age<\/label><input type='text' class='form-control' name='field-1sTj5N9sFvU3UNQ' id='field-1sTj5N9sFvU3UNQ'  \/><\/div><div class=\"erf-header erf-element-width-12\"><h4  data-non-input='1' data-ref-label='ref-gViMcIJA' data-ref-id='ref-vIZu3vVz' class='' >Reason for Request for Assistance<\/h4><\/div><div class=\"erf-textarea form-group field-field-f0LCOdJJAp7aLLN erf-element-width-12\"><label for=\"field-f0LCOdJJAp7aLLN\" class=\"erf-textarea-label\">Situation Causing Request for Assistance<span class=\"erf-required\">*<\/span><\/label><textarea class='form-control' name='field-f0LCOdJJAp7aLLN' required='required' id='field-f0LCOdJJAp7aLLN' ><\/textarea><\/div><div class=\"erf-text form-group field-field-kTEwFtFlLDnAIod erf-element-width-12\"><label for=\"field-kTEwFtFlLDnAIod\" class=\"erf-text-label\">Assistance Requested<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-kTEwFtFlLDnAIod' required='required' id='field-kTEwFtFlLDnAIod'  \/><\/div><div class=\"erf-text form-group field-field-BQmggFKAzQfdrBV erf-element-width-12\"><label for=\"field-BQmggFKAzQfdrBV\" class=\"erf-text-label\">Assistance Last Requested<\/label><input type='text' class='form-control' name='field-BQmggFKAzQfdrBV' id='field-BQmggFKAzQfdrBV'  \/><\/div><div class=\"erf-text form-group field-field-3pOLznsTPuiHAOO erf-element-width-12\"><label for=\"field-3pOLznsTPuiHAOO\" class=\"erf-text-label\">Attend Church Regularly?<span class=\"tooltip-element\" tooltip=\"Yes No\"><i class=\"fa fa-info\" aria-hidden=\"true\"><\/i><\/span><\/label><input type='text' class='form-control' name='field-3pOLznsTPuiHAOO' id='field-3pOLznsTPuiHAOO'  \/><\/div><div class=\"erf-text form-group field-field-kUBvXO5ljlG6MF1 erf-element-width-12\"><label for=\"field-kUBvXO5ljlG6MF1\" class=\"erf-text-label\">What church do you attend?<\/label><input type='text' class='form-control' name='field-kUBvXO5ljlG6MF1' id='field-kUBvXO5ljlG6MF1'  \/><\/div><div class=\"erf-header erf-element-width-12\"><h4  data-non-input='1' data-ref-label='ref-jrcgLc8q' data-ref-id='ref-W77LsdA1' class='' >Please complete the information below. Enter a 0 if it does not apply to you.<\/h4><\/div><div class=\"erf-header erf-element-width-12\"><h4  data-non-input='1' data-ref-label='ref-W57HZVh9' data-ref-id='ref-90XRliGq' class='' >Income:<\/h4><\/div><div class=\"erf-text form-group field-field-0bKemPdzK0cB9z2 erf-element-width-12\"><label for=\"field-0bKemPdzK0cB9z2\" class=\"erf-text-label\">Your Wages<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-0bKemPdzK0cB9z2' required='required' id='field-0bKemPdzK0cB9z2'  \/><\/div><div class=\"erf-text form-group field-field-pi0NKwjPIA9sXRv erf-element-width-12\"><label for=\"field-pi0NKwjPIA9sXRv\" class=\"erf-text-label\">Spouse's Wages<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-pi0NKwjPIA9sXRv' required='required' id='field-pi0NKwjPIA9sXRv'  \/><\/div><div class=\"erf-text form-group field-field-Ucr2fLUBmoiYrTz erf-element-width-12\"><label for=\"field-Ucr2fLUBmoiYrTz\" class=\"erf-text-label\">Other's Wages<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-Ucr2fLUBmoiYrTz' required='required' id='field-Ucr2fLUBmoiYrTz'  \/><\/div><div class=\"erf-text form-group field-field-sGNtingT5xL6LqD erf-element-width-12\"><label for=\"field-sGNtingT5xL6LqD\" class=\"erf-text-label\">AFDC<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-sGNtingT5xL6LqD' required='required' id='field-sGNtingT5xL6LqD'  \/><\/div><div class=\"erf-text form-group field-field-Ofuvr5T1jru15w8 erf-element-width-12\"><label for=\"field-Ofuvr5T1jru15w8\" class=\"erf-text-label\">Social Security (Retirement)<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-Ofuvr5T1jru15w8' required='required' id='field-Ofuvr5T1jru15w8'  \/><\/div><div class=\"erf-text form-group field-field-xSi9IR8LuTthATl erf-element-width-12\"><label for=\"field-xSi9IR8LuTthATl\" class=\"erf-text-label\">SSI<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-xSi9IR8LuTthATl' required='required' id='field-xSi9IR8LuTthATl'  \/><\/div><div class=\"erf-text form-group field-field-f8gx94MDzhfkSfk erf-element-width-12\"><label for=\"field-f8gx94MDzhfkSfk\" class=\"erf-text-label\">Retirement Benefits<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-f8gx94MDzhfkSfk' required='required' id='field-f8gx94MDzhfkSfk'  \/><\/div><div class=\"erf-text form-group field-field-MqQGotVESrUdeuF erf-element-width-12\"><label for=\"field-MqQGotVESrUdeuF\" class=\"erf-text-label\">Workman's Compensation<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-MqQGotVESrUdeuF' required='required' id='field-MqQGotVESrUdeuF'  \/><\/div><div class=\"erf-text form-group field-field-i2uMmuOb1j56b8g erf-element-width-12\"><label for=\"field-i2uMmuOb1j56b8g\" class=\"erf-text-label\">Unemployment Insurance<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-i2uMmuOb1j56b8g' required='required' id='field-i2uMmuOb1j56b8g'  \/><\/div><div class=\"erf-text form-group field-field-1BtDD0dCbgS0YI1 erf-element-width-12\"><label for=\"field-1BtDD0dCbgS0YI1\" class=\"erf-text-label\">Food Stamps<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-1BtDD0dCbgS0YI1' required='required' id='field-1BtDD0dCbgS0YI1'  \/><\/div><div class=\"erf-text form-group field-field-RwRF5zSytFL6glc erf-element-width-12\"><label for=\"field-RwRF5zSytFL6glc\" class=\"erf-text-label\">Utilities Allotment<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-RwRF5zSytFL6glc' required='required' id='field-RwRF5zSytFL6glc'  \/><\/div><div class=\"erf-text form-group field-field-O7A1sgZgtaQrdla erf-element-width-12\"><label for=\"field-O7A1sgZgtaQrdla\" class=\"erf-text-label\">Housing Allotment<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-O7A1sgZgtaQrdla' required='required' id='field-O7A1sgZgtaQrdla'  \/><\/div><div class=\"erf-text form-group field-field-tNOVgA5yZknhvxL erf-element-width-12\"><label for=\"field-tNOVgA5yZknhvxL\" class=\"erf-text-label\">Child Support<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-tNOVgA5yZknhvxL' required='required' id='field-tNOVgA5yZknhvxL'  \/><\/div><div class=\"erf-text form-group field-field-rILksmo8J9hyC1N erf-element-width-12\"><label for=\"field-rILksmo8J9hyC1N\" class=\"erf-text-label\">Other<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-rILksmo8J9hyC1N' required='required' id='field-rILksmo8J9hyC1N'  \/><\/div><div class=\"erf-text form-group field-field-GINm3u2heFaqOfB erf-element-width-12\"><label for=\"field-GINm3u2heFaqOfB\" class=\"erf-text-label\">Other<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-GINm3u2heFaqOfB' required='required' id='field-GINm3u2heFaqOfB'  \/><\/div><div class=\"erf-text form-group field-field-JWOEufRKH8723Pq erf-element-width-12\"><label for=\"field-JWOEufRKH8723Pq\" class=\"erf-text-label\">Total Monthly Income<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-JWOEufRKH8723Pq' required='required' id='field-JWOEufRKH8723Pq'  \/><\/div><div class=\"erf-header erf-element-width-12\"><h4  data-non-input='1' data-ref-label='ref-UgGeXRyw' data-ref-id='ref-OhwNikQ6' class='' >Expenses:<\/h4><\/div><div class=\"erf-text form-group field-field-zVHFkRyxNOR3LIQ erf-element-width-12\"><label for=\"field-zVHFkRyxNOR3LIQ\" class=\"erf-text-label\">Rent<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-zVHFkRyxNOR3LIQ' required='required' id='field-zVHFkRyxNOR3LIQ'  \/><\/div><div class=\"erf-text form-group field-field-Nd9WZEnetFQiWd0 erf-element-width-12\"><label for=\"field-Nd9WZEnetFQiWd0\" class=\"erf-text-label\">Electric<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-Nd9WZEnetFQiWd0' required='required' id='field-Nd9WZEnetFQiWd0'  \/><\/div><div class=\"erf-text form-group field-field-LvnehSZrfYlcl8M erf-element-width-12\"><label for=\"field-LvnehSZrfYlcl8M\" class=\"erf-text-label\">Propane\/Gas<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-LvnehSZrfYlcl8M' required='required' id='field-LvnehSZrfYlcl8M'  \/><\/div><div class=\"erf-text form-group field-field-zUf2V8kndh5a1To erf-element-width-12\"><label for=\"field-zUf2V8kndh5a1To\" class=\"erf-text-label\">Food<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-zUf2V8kndh5a1To' required='required' id='field-zUf2V8kndh5a1To'  \/><\/div><div class=\"erf-text form-group field-field-H1MaswEQuTSshl6 erf-element-width-12\"><label for=\"field-H1MaswEQuTSshl6\" class=\"erf-text-label\">Water<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-H1MaswEQuTSshl6' required='required' id='field-H1MaswEQuTSshl6'  \/><\/div><div class=\"erf-text form-group field-field-z1YQT1FLeqlLtEx erf-element-width-12\"><label for=\"field-z1YQT1FLeqlLtEx\" class=\"erf-text-label\">Medical Payments<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-z1YQT1FLeqlLtEx' required='required' id='field-z1YQT1FLeqlLtEx'  \/><\/div><div class=\"erf-text form-group field-field-F2c9TvQDUlV5W8M erf-element-width-12\"><label for=\"field-F2c9TvQDUlV5W8M\" class=\"erf-text-label\">Loan Payments<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-F2c9TvQDUlV5W8M' required='required' id='field-F2c9TvQDUlV5W8M'  \/><\/div><div class=\"erf-text form-group field-field-t4banPoOdIjMMcw erf-element-width-12\"><label for=\"field-t4banPoOdIjMMcw\" class=\"erf-text-label\">Credit Card Payments<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-t4banPoOdIjMMcw' required='required' id='field-t4banPoOdIjMMcw'  \/><\/div><div class=\"erf-text form-group field-field-L8x7XI66GEyf4XT erf-element-width-12\"><label for=\"field-L8x7XI66GEyf4XT\" class=\"erf-text-label\">Lot Rent\/Land Payments<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-L8x7XI66GEyf4XT' required='required' id='field-L8x7XI66GEyf4XT'  \/><\/div><div class=\"erf-text form-group field-field-qOT1EFJ9zGTsZGH erf-element-width-12\"><label for=\"field-qOT1EFJ9zGTsZGH\" class=\"erf-text-label\">Mortgage<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-qOT1EFJ9zGTsZGH' required='required' id='field-qOT1EFJ9zGTsZGH'  \/><\/div><div class=\"erf-text form-group field-field-OCg4Sk6BaD9MOcJ erf-element-width-12\"><label for=\"field-OCg4Sk6BaD9MOcJ\" class=\"erf-text-label\">Insurance<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-OCg4Sk6BaD9MOcJ' required='required' id='field-OCg4Sk6BaD9MOcJ'  \/><\/div><div class=\"erf-text form-group field-field-c6gcYE8snWnmHUM erf-element-width-12\"><label for=\"field-c6gcYE8snWnmHUM\" class=\"erf-text-label\">Clothing<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-c6gcYE8snWnmHUM' required='required' id='field-c6gcYE8snWnmHUM'  \/><\/div><div class=\"erf-text form-group field-field-LGVRkfXD5i6rZNF erf-element-width-12\"><label for=\"field-LGVRkfXD5i6rZNF\" class=\"erf-text-label\">Other<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-LGVRkfXD5i6rZNF' required='required' id='field-LGVRkfXD5i6rZNF'  \/><\/div><div class=\"erf-text form-group field-field-lw4T9gop8q0hgI1 erf-element-width-12\"><label for=\"field-lw4T9gop8q0hgI1\" class=\"erf-text-label\">Other<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-lw4T9gop8q0hgI1' required='required' id='field-lw4T9gop8q0hgI1'  \/><\/div><div class=\"erf-text form-group field-field-7djaiXBs2yzvLn3 erf-element-width-12\"><label for=\"field-7djaiXBs2yzvLn3\" class=\"erf-text-label\">Total Expenses<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-7djaiXBs2yzvLn3' required='required' id='field-7djaiXBs2yzvLn3'  \/><\/div><div class=\"erf-checkbox-group form-group field-field-rb6TzxY6gRVr5JQ erf-element-width-12\"><label for=\"field-rb6TzxY6gRVr5JQ\" class=\"erf-checkbox-group-label\"><i class='erforms-icon fa fa-circle'><\/i>The Information I have provided is complete and accurate (true). I give God's Helping Hands permission to contact other Ministries, agencies utilities, organizations, etc in order for the interviewer to make an accurate assessment of my situation.<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"field-rb6TzxY6gRVr5JQ-0\" name='field-rb6TzxY6gRVr5JQ[]' class='form-control' multiple='1'  type=\"checkbox\" value=\"Yes\" \/><label for=\"field-rb6TzxY6gRVr5JQ-0\">I agree<\/label><\/div><\/div><\/div><div class=\"erf-text form-group field-field-qQbQxetKkH532nx erf-element-width-12\"><label for=\"field-qQbQxetKkH532nx\" class=\"erf-text-label\">Please type name<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-qQbQxetKkH532nx' required='required' id='field-qQbQxetKkH532nx'  \/><\/div><div class=\"erf-text form-group field-field-aILPdfezWUUaWKt erf-element-width-12\"><label for=\"field-aILPdfezWUUaWKt\" class=\"erf-text-label\">Date<span class=\"erf-required\">*<\/span><\/label><input type='text' class='form-control' name='field-aILPdfezWUUaWKt' placeholder='mm\/dd\/yyyy' required='required' id='field-aILPdfezWUUaWKt'  \/><\/div><div class=\"erf-button form-group field-button-12015226404 erf-element-width-12\"><button type='submit'class='btn btn-default'name='button-12015226404'id='button-12015226404'>Send<\/button><\/div>                    <\/div> \n                <\/div>    \n\n                <div class=\"erf-external-form-elements\">\n                    \n                    \n                    \n\n                    \n                                        <div class=\"erf-errors\" style=\"display:none\">\n                        <span class=\"erf-errors-head erf-error-row\">Error occured. Please confirm your data and submit again:<\/span>\n                        <div class=\"erf-errors-body\">\n                                                    <\/div> \n                    <\/div>\n\n                <\/div>\n                <!-- Contains multipage Next,Previous buttons -->\n                <div class=\"erf-form-nav clearfix\"><\/div> \n\n                <!-- Single page form button -->\n                <div class=\"erf-submit-button clearfix\"><\/div>\n\n\n                <input type=\"hidden\" name=\"erform_id\" value=\"47\" \/>\n                <input type=\"hidden\" name=\"erform_submission_nonce\" value=\"e0264eb76b\" \/>\n                <input type=\"hidden\" name=\"action\" value=\"erf_submit_form\" \/>\n\n            <\/form>\n            \n<\/div>\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":57,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"hide_page_title":"","_coblocks_attr":"","_coblocks_dimensions":"","_coblocks_responsive_height":"","_coblocks_accordion_ie_support":"","footnotes":""},"class_list":["post-16","page","type-page","status-publish","has-post-thumbnail","hentry"],"_links":{"self":[{"href":"http:\/\/ghhcrf.com\/blog\/wp-json\/wp\/v2\/pages\/16","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/ghhcrf.com\/blog\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"http:\/\/ghhcrf.com\/blog\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"http:\/\/ghhcrf.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/ghhcrf.com\/blog\/wp-json\/wp\/v2\/comments?post=16"}],"version-history":[{"count":17,"href":"http:\/\/ghhcrf.com\/blog\/wp-json\/wp\/v2\/pages\/16\/revisions"}],"predecessor-version":[{"id":88,"href":"http:\/\/ghhcrf.com\/blog\/wp-json\/wp\/v2\/pages\/16\/revisions\/88"}],"wp:featuredmedia":[{"embeddable":true,"href":"http:\/\/ghhcrf.com\/blog\/wp-json\/wp\/v2\/media\/57"}],"wp:attachment":[{"href":"http:\/\/ghhcrf.com\/blog\/wp-json\/wp\/v2\/media?parent=16"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}