HOUSEHOLD MEMBERS (please include head of household)

Transcription

1 Date: ST. TAMMANY PARISH COMMUNITY ACTION AGENCY WAP Applicatin Last Name: First Name: Address: City: Zip Cde Telephne Number: Cell: MARITAL STATUS: Single (Never Married) Married Separated Divrced Widwed Hme Status: Own Rent Raised Hme Slab Fundatin Mbile hme Electric Natural Gas Prpane Bth HOUSEHOLD MEMBERS (please include head f husehld) NAME RELATIONSHIP SSN DOB RACE SEX INCOME 1

2 Please read carefully and sign: CERTIFICATION OF TRUE AND CORRECT INFORMATION Yu will be subject t criminal prsecutin under title 18 f the U.S. cde if yu knwingly, give false, incrrect, r incmplete infrmatin during this applicatin prcess in rder t btain assistance Failure shall result t frfeiture r ineligibility and in terminatin f service and the repayment f such services. I understand prf f all statements may be required and I give permissin t St. Tammany Parish Cmmunity Actin t cntact the apprpriate public r private surces fr verificatin and exchange f infrmatin. An appeal f a decisin may be requested if it is cnsidered unfair r if there has been a vilatin f civil rights. THIS AGENCY DOES NOT DISCRIMINATE BECAUSE OF RACE, RELIGION, SEX, NATIONAL ORIGIN OR DISABILITY. APPLICANT S SIGNATURE: DATE: CAA REPRESENTATIVE SIGNATURE: DATE: 2

3 ST. TAMMANY PARISH Items Needed fr Weatherizatin Picture ID r Driver s License fr everyne in the husehld wh is 18 years r lder. Prf f residency if the address n picture ID des nt match address n the utility bill. (Examples: lease, water bills, cable bill, rent receipt, check stubs, fd stamp printut) Scial Security Cards fr every member f the husehld. Birth Certificates fr all children 5 years ld and yunger; birth letters frm hspital r sht recrds are als permitted. Utility Bill printut fr up t 6 mnths f service. CLECO, WST, r ENTERGY custmers may btain this printut frm a lcal ffice. Yu may btain ne fr yur Gas OR bring in latest bill. Fd Stamp Printut if applicable, the mst current fd stamp letter. Yu can btain this printut n the LACAFE prtal website. Prf f Unearned Incme 2016 Scial Security/SSI Award Letter. (MUST SHOW YOUR MONTHLY INCOME) Mnthly Pensin statement Cntributin frm (this frm may be picked up frm ur ffice and filled ut by anyne wh cntributes financially t yur husehld) Unemplyment statement Prf f Earned Incme Last 4 CURRENT and CONSECUTIVE paycheck stubs. If yu cannt find the last 4 check stubs yu can btain an Emplyment Verificatin Frm frm ur ffice that yur emplyer my fill ut. If yu have just started emplyment yu must pick up an emplyment verificatin frm frm ur ffice and have yur emplyer fill ut. If claiming NO INCOME yu must prvide prf f hw yu are maintaining. Self-Emplyment applicants must prvide their current Federal Incme Tax Returns with invices, schedules, and receipts fr wrk perfrmed. MUST have filed mst recent taxes. Other INCOME MUST BE REPORTED FOR ANYONE 18 OR OLDER LIVING IN THE HOUSEHOLD ALL DOCUMENTATION IS REQUIRED AT THE TIME OF APPOINTMENT

4 ST. TAMMANY PARISH AUTHORIZATION FOR THE RELEASE OF INFORMATION Date: Name/Address f Agency: St. Tammany Parish Gvernment Department f Health and Human Services Cmmunity Actin Agency Cmmunity Actin Agency 520 Old Spanish Trail 3C 1301 N. Flrida St. Slidell, La Cvingtn, La (985) (985) Authrizatin: I authrize the release f any infrmatin (including dcumentatin and ther materials) pertinent t eligibility fr participatin under any f the fllwing prgram: Weatherizatin Assistance Prgram I authrize the abve named rganizatin t btain infrmatin abut self r any husehld member that is pertinent t eligibility fr r participatin in assisted husing prgram. The inquiries may be made abut the fllwing: Credit Histry Emplyment, Incme, Pensins TANF Assistance FITAP Assistance Child Supprt Scial Security Bank Depsits and Assets Mrtgage Payment Utilities Federal r State taxes SNAP Assistance Life Insurance Hazard Insurance Fld Insurance I authrize the release f infrmatin frm the fllwing rganizatins (s): Banks r ther financial institutin Credit Bureaus Emplyers (past and present) Department f Children and Family Services Business and Career Slutins Center U.S. Scial Security Administratin U.S. Depart f Veteran Affairs Utility Cmpanies State Emplyment Agencies

5 I agree that phtcpies f this authrizatin may be used fr the purpses stated abve. Printed Name Signature & Date *Original is retained by requesting rganizatin.