HOUSING ASSISTANCE PROGRAM APPLICATION FOR EMERGENCY ASSISTANCE

Size: px

Start display at page:

Download "HOUSING ASSISTANCE PROGRAM APPLICATION FOR EMERGENCY ASSISTANCE"

Baldwin Farmer
6 years ago
Views:

1 APPLICATION FOR EMERGENCY ASSISTANCE Client Eligibility Requirements Clients must be living with AIDS or HIV The request for assistance must be an unexpected emergency or crisis beyond the applicant s control and must be documented; the client s AIDS or HIV status alone does not in itself constitute an emergency Household gross income must be within the income guidelines (30% of area median income) Clients must live in, or be moving to, a jurisdiction within either the Northern or Northwest region of Virginia Financial requests will only be processed for approved HAP expenses: rent, mortgage, security deposit, 1 st month s rent, utilities and, in some cases, basic telephone services (landlines, not cell) Clients can only apply for one month of assistance per request unless the client is in arrears. The client cannot apply for months in advance. Clients are eligible to apply for up to 21 weeks of assistance in their eligibility year. Application Procedure All forms must be filled out in their entirety. Documents with sections left blank will be considered incomplete and returned. Outcome will not be determined until all the required documentation is received. The application must be signed by the client (and worker if applicable. Please note if the client is self-referring, a self referral form must be submitted). If a worker is submitting the request, they must ensure that client meets the mandatory eligibility requirements Clients applying for a security deposit for a second time within a two-year period must submit a security deposit return form completed by the landlord. The worker must ensure that all supporting documentation is submitted with the application and the documentation is accurate. Signatures on all documents indicate that the worker and/or client attest that all the information is true and accurate. The following must be submitted with request: Documentation about the crisis that is creating this financial emergency Current lease (client s name must be on lease) & letter of approval from landlord on letterhead, listing rent and/or security deposit (must include landlord s SS#, address, phone and signature) Utility bills in client s name (if requesting utility assistance) Eviction notice (if issued) W-9 form filled out by landlord Proof of income for all household members Current Bank Statement Proof of income for all household members over the age of 18 includes one or more of the following: 2 most recent pay stubs SSI/SSDI letter for current year Bank account statement with deposits Unemployment/Worker s Compensation earnings TANF/GR check Proof of food stamps Proof that client is receiving assistance from other organizations Signed letter on company letterhead regarding wages or termination If the client does not have income or has a reduction in income, the client and household members must provide a Zero Income Affidavit form, termination or reduction letter (if applicable), evidence that they are applying for unemployment benefits, supporting documentation of a job search and a current bank statement. PLEASE NOTE: The following are items that will be kept on file and will not need to be re-submitted until they expire or change: leases, annual SSI/SSDI letters and W-9 forms Approval Process The HAP coordinator will notify referring case manager/health professional/social worker of the outcome within 3 business days of submission provided all documentation has been submitted Clients have the right to appeal an unfavorable decision within 2 business days of being informed of the decision by faxing a letter to HAP. A decision on the appeal will be made within 3 business days. If the client has further concerns after the decision of the appeal he/she may follow the NVFS Grievance Procedure. Emergency Assistance grant checks will be made payable to vendors and mailed directly to vendors.

2 APPLICATION FOR EMERGENCY ASSISTANCE To be completed and verified by client s case manager/health professional/social worker. All supporting documentation must be submitted with application. HAP is under no obligation to approve an application (This application is strictly confidential and will be utilized solely by the HAP for HIV/AIDS related Emergency Assistance) Referring Agency Name/Address (if applicable): Date of Application: Referring Worker Name (if applicable): Type of Assistance being requested: Rent Assistance Utility Assistance Mortgage Assistance Telephone#: Fax #: First Month Rent Security Deposit Both Security and First Month rent Client Information: Client Name: DOB: SS#: Home Telephone: Work Telephone: Street Address: Client City: State: Zip Code: County: Household Composition: (Everyone residing in the home must be listed.) First & Last Name DOB Sex Relationship Race Ethnicity Client Client Health Information: Current HIV Status and Condition Warranting Assistance: Please check the client s current Housing Status: Homeless/Street Hospitalized Homeless/Shelter Incarcerated Living w/family or friends Transitional Housing Substance Abuse/Detox Section 8 rental Psychiatric Facility Owner-Occupied Renting (alone) (non subsidy) Renting w/spouse/partner (no subsidy) Renting (w/roommate) Renting a Room 2

3 Number of Bedrooms: Room Efficiency Household Expense/Income Statement Expenses Amount Applicant Monthly Net Income (for all household members) Rent/mortgage Wages/Salary Property Taxes Unemployment Property Insurance Pension Gas/Elec./Utility SSDI Water/Sewage/Garbage SSI Telephone Child Support Groceries TANF Work/school Expenses General Relief Health Insurance Food Stamps Prescriptions Other Health care other Other Car Payment (s) Income from spouse Gas/Vehicle Repairs Income from adult children Tolls/bus fare/parking Total Auto Insurance Taxes/Registration Child Day Care Alimony/Child Support Credit Card Loans Other Loans Other Total Discretionary Monthly Expenses Beauty/Barber Shop Cable Entertainment General Recreation Clothing Purchases Laundry/Dry cleaning Pet Care Pager/Cell Phones Cigarettes/Alcohol Religious Organizations Gifts Other Total Income/Expense Summary Total Income Total Expenses Monthly Difference ***Please include current Bank Statement with Application*** Determination of Emergency Financial Need Explain the dollar amount, what type of assistance needed and what month it is for (EX: December s electric bill for $120.00): 3

4 What created this particular financial emergency? Why is it urgent? Discuss the financial plan your client have developed to prevent this situation or similar situations from occurring (i.e.: finding a payee, getting on budget plan with utility company). Does client need financial counseling? Yes No If No, explain: Please list organizations where client has requested assistance for their current need and the outcome of the request I do herby swear and attest that, to the best of my knowledge, all of the information about my client is true and complete. Signature of Applicant s Case Manager (if applicable) Date Signature of Applicant Date 4

5 APPLICATION FOR EMERGENCY ASSISTANCE CLIENT AUTHORIZATION TO RELEASE INFORMATION I, (the client), allow the NVFS staff administering the HAP program, other Northern Virginia HAP sub-contractors, the HUD administrative agent (Northern Virginia Regional Commission), my physician, and my case manager to share information. I also authorize NVFS staff administering HAP to contact the respective vendor(s) and employers (past, present or potential) to gain further information. This release expires after all reviews of the HOPWA funding year in which this application was submitted. I may revoke my authorization at anytime with a notarized letter. I also understand that certain cases, such as those involving Protective Services, Court Service Unit, court orders or subpoenas, may lead to disclosure of information not withstanding refusal, revocation or expiration of my consent. Additionally, I do not require that the listed parties tell me when they share information about me. I have read and understood and agree to the above information. Client s Signature: Date: 5

EMERGENCY FINANCIAL ASSISTANCE Zero Income Affidavit HOUSING OPPORTUNITIES FOR PERSONS WITH AIDS I, (client s name), have applied for emergency or rental assistance through the HUD Housing

6 EMERGENCY FINANCIAL ASSISTANCE Zero Income Affidavit HOUSING OPPORTUNITIES FOR PERSONS WITH AIDS I, (client s name), have applied for emergency or rental assistance through the HUD Housing Opportunities for Persons with AIDS (HOPWA) program. Program regulations require verification of all income from participating households. Income includes but is not limited to: Gross wages, salaries, overtime pay, commissions, fees, tips and bonuses Net income from operation of a business or from rental or real personal property Interest, dividends and other net income of any kind for real personal property Periodic payments received from Social Security, annuities, insurance policies, retirement funds, pensions, disability or death benefits and other similar types of period receipts Lump sum payment(s) for the delayed start of a periodic payment (except as provided in 24 CFR (b)(5)) Payments in lieu of earnings, such as unemployment and disability compensation, worker s compensation, and severance pay Public assistance Alimony and child support payments (whether through the court system or not) Regular pay, special pay and allowances of a head of household or spouse who is a member of the Armed Forces (whether or not living in the dwelling) Regular monetary gifts from family and/or friends I have stated during this verification process that I have no income at this time. I have not received income since. I do not expect to receive any income until. I applied for (other financial assistance) on (date). I understand that any misrepresentation of information or failure to disclose information requested on this form may disqualify me from participation in the HOPWA program, and may be grounds for termination of assistance. WARNING: It is unlawful to provide false information to the government when applying for federal public benefit programs per the Program Fraud Civil Remedies Act of 1986, 31 U.S.C I certify that the above information is true and correct. I also understand that it is my responsibility to report all changes to my household composition or income in writing to within ten (10) business days of such change. Signature: Date: Witness: Date: Case Manager/Care Coordinator s Notes: 6

7 EMERGENCY FINANCIAL ASSISTANCE SECURITY DEPOSIT FORM The undersigned, (name of tenant(s) hereby assign to NVFS - HAP all our right, title, and interest to the security deposit paid to (Landord s name) (Landlord s complete address) In the amount of $. (Security Deposit Only) The security deposit is paid in connection with the rental of the property at: Street Address City: State: Zip Code: This financial assistance is considered a loan to the above named from the NVFS-HAP program. Therefore, upon expiration or termination of the lease/tenancy, the security deposit must be refunded to us. If the tenant moves or is evicted before the lease expires please contact our program. If the funds are used for repairs that the tenant has caused, the landlord is required to return any receipts showing the associated costs and any remaining funds. Funds cannot be used for unpaid rent. It is understood that the security deposit shall be refunded to, Attention HAP, White Granite Drive, Oakton, VA Tenant Signature Date Landlord Signature Date 7

8 EMERGENCY FINANCIAL ASSISTANCE SELF-REFERRAL FORM (Use if there is not a case manager) Client Name: Address: Telephone: HIV Status: What Type of Assistance is needed? What caused the Emergency? Amount Requested: Today s Date: 8

9 EMERGENCY FINANCIAL ASSISTANCE Housing Plan (Most be completed with when requesting any type of assistance) Please state what you actively plan to do to stabilize your housing situation for the future. Example: Since my hours have been reduced, I will actively look for additional employment to make up for those lost hours and income. (Documentation must be submitted to show your efforts towards achieving your previously stated housing plan if this is not your first request for assistance and adjustments to your plan must be made). Client Signature and Date: 9

10 NORTHERN VIRGINIA FAMILY SERVICE CLIENT RIGHTS, RESPONSIBILITIES AND PROCEDURES All Clients have the Right: 1. To be treated fairly and without discrimination. 2. To be treated in a professional, respectful and non-coercive manner. 3. To confidentiality and privacy, unless NVFS staff is required by law under the following circumstance to share confidential information; a) you are in imminent danger of harming yourself or others; b) suspicion of child or elder abuse or neglect; c) court order. 4. To make informed choices and decide for themselves the services they want. 5. To be a part of decisions about the services provided. 6. To review their own record of service provision, have a copy sent to qualified professionals (at their own expense), and to insert a statement in their record. When a Client is enrolled in a Program or Service, he or she may expect to receive: 1. Information about the rules, expectations, and requirements to participate in the specific program or service. 2. Notification of what behaviors or factors that may result in the withdrawal of services or termination from the program. 3. Information about the days and times when services and staff are available. 4. Information about how to make a complaint or to appeal a service decision, and to expect no retaliatory actions in response to their complaint. All Clients have the Responsibility: 1. Let the staff know if they don t understand their rights and responsibilities, or any program requirements. 2. To notify staff if they are unable to keep an appointment or scheduled meeting. 3. To actively participate in the services offered. 4. To let staff know if they are dissatisfied with the service(s) and give staff a chance to correct the problem(s). 5. To let staff know if they need alternate forms of communication, including the use of translators, signlanguage signers, TTD machines, and other communication tools. CLIENT GRIEVANCE PROCESS To access the grievance procedure when you, the client, feel that your rights have been violated: 1. First, discuss your concerns with your assigned direct service worker or case manager. If you do not feel that you can discuss your concerns with them, contact the direct supervisor. 2. If you feel the supervisor has not addressed your concerns, contact the Program Management Team (program manager and/or Program VP). At that time a case review will be conducted to review your concern and assure that all agency and legal guidelines have been followed. 3. If you are not satisfied with the Management Team response, you may file a written grievance with the Senior Vice President of Programs. This written notification should include your complaint and all steps that have been taken to resolve this concern. 4. The Senior VP of Programs will review the case and respond in writing to you within ten (10) business days of receipt of the grievance. 5. If you are not satisfied you may request in writing that the President/ CEO review the grievance. The President CEO will respond in writing to you within ten (10) business days. This decision is final. I have reviewed and received a copy of these rights, responsibilities, and procedures. Printed Name Signature Date Update:

Last Name First Name Middle. Address Number & Street City State Zip Code. Date of Birth Applicant Co-applicant / / / / Month Day Year Month Day Year

Last Name First Name Middle. Address Number & Street City State Zip Code. Date of Birth Applicant Co-applicant / / / / Month Day Year Month Day Year PARKVIEW APARTMENTS HOUSING APPLICATION Mr. Ms. Miss Date: Mrs. Mr. & Mrs. Last Name First Name Middle Address Number & Street City State Zip Code ( ) ( ) Home Phone Number Alternate Contact Number How