PLEASE INCLUDE WITH YOUR APPLICATION ANY ITEMS CHECKED BELOW AND CIRCLE EITHER YES OR NO:

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1 Program Application The Salvation Army HeatShare Program is a last resort utility assistance program for those who have exhausted all other public funding available in their area. Funding is available only once per calendar year to any qualifying household. PLEASE INCLUDE WITH YOUR APPLICATION ANY ITEMS CHECKED BELOW AND CIRCLE EITHER YES OR NO: Have you applied for Energy Assistance at your Community Action Agency? Yes No If no: STOP, you must first apply for Energy Assistance with the Community Action Agency in your area. If yes: Include a copy of your grant or denial letter. Have you applied for Emergency Assistance at your County Social Service Office? Yes No If no: STOP, you must first apply for Emergency Assistance with the County Social Services office in your area. If yes: Include a copy of your grant or denial letter. Have you received assistance from The Salvation Army HeatShare program in the past 12 months? Yes No If no: Please continue filling out the application. If yes: STOP. You are only eligible to receive assistance from the Salvation Army HeatShare program once every 12 months. Verification of Income: A check stub from either your employer, of the top portion of the MFIP, GA or other assistance checks, or a letter you ve received stating the amount of social security or disability benefits, etc. Utility Bill: A copy of the past due utility bill that you would like help with which includes your name, address, account number and the utility company s name, address, and telephone number. If you are seeking help with propane, fuel oil, or wood have your vendor fax the Salvation Army HeatShare office an estimate worth $ Verification of Emergency: A copy of one of the following that has occurred in the past days; either a medical bill, repair bill, verification of change in income or lost wages, funeral bill, or divorce. (This would be an unexpected emergency that you could prove on paper that has put you behind in paying your utility or fuel bill in the last days.) Authorization for Release of Information Form: Must be filled out and signed. The Salvation Army Data Privacy Notice and Consent Form: A signed consent form for each adult in the household is needed. There are two included with your application. The required documentation checked above, along with your completed application, should be sent in the enclosed envelope. Please send completed applications to Joe T. 400 HWY 10 S. St. Cloud MN, Incomplete applications will need to be returned to you. Once all documentation has been received, we will inform you of your grant or denial status. If you have any questions, please contact our office at , or write to us at: The Salvation Army, HeatShare Program, 400 HWY 10 S, Saint Cloud, MN Page 1 of 6 Revised 11/16/2016

2 SERVICE DATE: APPLICANT S INFORMATION CHECK HERE IF YOU ARE CURRENTLY DISCONNECTED APPLICANT S NAME: FIRST MI LAST HOME PHONE NUMBER: BIRTH DATE: APPLICANT S STREET ADDRESS: APT #: CITY: COUNTY: STATE: ZIP: GENDER: FEMALE MALE RACE: U.S. MILITARY VETERAN? YES NO ANYONE IN THE HOUSEHOLD CURRENTLY ACTIVE IN THE MILITARY? YES NO ARE YOU AN IMMIGRANT? YES NO Africa Eastern Europe Middle East Chicano/Latino/Hispanic PLEASE LIST ALL OTHER MEMBERS OF THE HOUSEHOLD AND THEIR INFORMATION BELOW: FIRST AND LAST NAME RELATION TO HEAD OF HOUSEHOLD DATE OF BIRTH RACE GENDER FEMALE OR MALE? ELIGIBILITY REQUIREMENTS (CHECK ALL THAT APPLY): SENIOR CITIZEN (AGE 65 OR OLDER) RECEIVE DISABILITY BENEFITS (SSI, SSDI, RSDI, DISABLED VETERANS) UNEPECTED/UNPREVENTABLE FINANCIAL CRISIS EPERIENCED IN THE PAST DAYS. CASEWORKERS PORTION TO FILL OUT Applicant has made payments of at least 3% of their income to their utilities in last 6 months? Yes No Status of application: Date applicant notified of grant or denial: Data entry completed by: ServicePoint #: GAS Date of guarantee: Amount: $ Person taking guarantee: ELECTRIC, PROPANE, FUEL OIL OR WOOD Date of guarantee: Amount: $ Person taking guarantee: MONTH END STATISTICS Date of appointment: / / Was this a home visit? Yes No # Referrals provided (6114): # Referrals to other community resources provided (6410): Was there spiritual visitation during appointment? Yes No # of visitation minutes (2460): Did you pray with the client? Yes No Total persons visited (2470): Notes about applicant s crisis situation: Page 2 of 6 Revised 11/16/2016

3 APPLICANT S NAME: APPLICANT S MONTHLY SPENDING PLAN DATE: HOUSING MONTHLY EPENSES RENT/MORTGAGE WATER HEAT ELECTRICITY TELEPHONE TRASH REMOVAL NECESSITIES FOOD CLOTHING TOILETRIES TRANSPORTATION CAR PAYMENT CAR GAS INSURANCE BUS FARE MEDICAL MEDICATION PAST DUE MEDICAL PAST DUE DENTAL INSURANCE FAMILY CHILD CARE DIAPERS OTHER CREDIT CARDS RENTAL LOANS STUDENT LOANS CABLE TV & INTERNET CIGARETTES ALCOHOL OTHER $ TOTAL EPENSES $ MONTHLY INCOME FOR ALL HOUSEHOLD MEMBERS EARNED INCOME UNEMPLOYMENT INS SSI SSDI RSDI VA SERVICE DISABILITY PRIVATE DISABILITY INS. WORKER S COMPENSATION MFIP/TANF GENERAL ASSISTANCE SOCIAL SECURITY RETIREMENT BENEFITS VETERAN S BENEFITS PENSION/ANNUITY CHILD SUPPORT ALIMONY/SPOUSAL SUPPORT INTEREST/DIVIDEND INCOME MN SUPPLEMENTAL AID STUDENT GRANT TRIBAL FUNDS NON-CASH INCOME SUPPLEMENTAL NUTRITION ASSIST. PROG. SPECIAL SUPPLEMENTAL NUTRITION PROG. FOR WIC TANF CHILD CARE SERVICES TANF TRANSP. SERVICES OTHER TANF FUNDED PROGRAMS SECTION 8, PUBLIC HSG., OTHER ONGOING RENTAL ASSIST. TEMP. RENTAL ASSIST. OTHER SOURCE PLEASE SUBTRACT YOUR TOTAL EPENSES FROM YOUR TOTAL INCOME. TOTAL INCOME $ TOTAL EPENSES $ DIFFERENCE IS $ Page 3 of 6 Revised 11/16/2016

4 TENNESSEN WARNING AND AUTHORIZATION FOR RELEASE OF INFORMATION FORM Data Privacy Rights for Applicants/Recipients of Program Sponsored by the Salvation Army YOUR RIGHTS: Under the Minnesota Data Privacy Act, you have the right to know how the information you provide on the application for a program will be used. USE OF INFORMATION: The information you provide will be used to: Determine your eligibility for a specific program. Provide statistical data to evaluate the effectiveness of the program. Provide data on the demographics on those using the program. Enable Salvation Army staff to assist you in identifying resources. Outside of statistical information and demographics, private and confidential data will not be provided to anyone without your informed consent. REFUSAL TO PROVIDE DATA: You may refuse to provide the data. This may prevent you from obtaining services from certain programs that require the data and our services to you may be limited. Providing false information can lead to your removal from the program and possibly denial of services in other Salvation Army programs for one year. You do not have to provide a Social Security Number to be eligible for our programs. Federal Privacy Act and Freedom of Information Act dictate the use of the Social Security Number. We may use it for computer matches, programs reviews, and audits. We will ask you for your Social Security Number for these purposes only, and will not share that information unless dictated by law. AUTHORIZATION BY LAW TO SHARE INFORMATION: The Salvation Army is authorized by law to share the data with the staff at the Minnesota Department of Children, Families and Learning, Minnesota Department of Human Services, the United States Departments of Health and Human Services, Labor, Housing and Urban Development and Agriculture. With your informed consent, we may also share it with community agencies, local and state human service agencies, local government, educational programs and other agencies that help you. I hereby authorize The Salvation Army s HeatShare staff to seek from and/or release to the agencies below, information for services I am requesting. I understand that I may cancel this consent in writing prior to the information being released. This consent expires one year after signing. Name of your Electric Company: Name of your Gas Company: APPLICANT S NAME: APPLICANT S ADDRESS: APPLICANT S CITY, STATE, AND ZIP: APPLICANT S SIGNATURE: CASEWORKER S PORTION TO FILL OUT HeatShare Caseworker s Signature: DATE: Date: Page 4 of 6 Revised 11/16/2016

5 The Salvation Army Client Data Management System Client Privacy Notice & Consent Form NOTICE: We collect personal information directly from you for reasons outlined in The Salvation Army Client Data Management System Privacy Policy and Guidelines. We may be required to collect some personal information by law or by organizations that provide funds for this program. Other personal information we collect is important to manage our programs, to improve services, and to better understand the needs of those we serve. We only collect information we consider to be appropriate. The collection and use of all personal information is guided by strict standards of confidentiality. A copy of our privacy policy is available to all clients upon request. YOUR RIGHTS: You have the right to a copy of the information about you in The Salvation Army Client Data Management System as outlined in the Client Data Management System Privacy Policy. You have the right to correct mistakes in information about you. If you have a complaint about the performance of any Salvation Army staff member, intern or volunteer, or feel treated unfairly in any way, you can follow the grievance policy steps outlined in The Salvation Army Client Data Management System Privacy Policy. Grievances may be formally filed by making an appointment to speak with or by submitting a written complaint to The Salvation Army Unit Director at the location you are being served. If you do not want your name, social security number, or date of birth entered in The Salvation Army Client Data Management System, tell the intake worker and circle the applicable section below. The Salvation Army will not refuse to help you for denying this. They will enter you into the system as an anonymous individual and keep your identifiable information separate. If applicable, circle this statement in italics: I am refusing to allow my identifiable information to be entered in The Salvation Army Client Data Management System and understand that my intake information will be entered as an anonymous client. I understand that my identifiable information will be stored separately in a secure database for anonymous clients. SIGNED CONSENT Each adult, emancipated minor, or unaccompanied youth must sign for him or herself. A parent/guardian should sign for children under the age of 18. My signature shows that I permit you to enter my personal information into a Client Data Management System. Print Name Client / / Date of Birth / / / / Signature of Client or Guardian Date Signed Signature of Witness Date Signed If applicable, dependent child under 18: Page 5 of 6 Revised 11/16/2016

6 The Salvation Army Client Data Management System Client Privacy Notice & Consent Form NOTICE: We collect personal information directly from you for reasons outlined in The Salvation Army Client Data Management System Privacy Policy and Guidelines. We may be required to collect some personal information by law or by organizations that provide funds for this program. Other personal information we collect is important to manage our programs, to improve services, and to better understand the needs of those we serve. We only collect information we consider to be appropriate. The collection and use of all personal information is guided by strict standards of confidentiality. A copy of our privacy policy is available to all clients upon request. YOUR RIGHTS: You have the right to a copy of the information about you in The Salvation Army Client Data Management System as outlined in the Client Data Management System Privacy Policy. You have the right to correct mistakes in information about you. If you have a complaint about the performance of any Salvation Army staff member, intern or volunteer, or feel treated unfairly in any way, you can follow the grievance policy steps outlined in The Salvation Army Client Data Management System Privacy Policy. Grievances may be formally filed by making an appointment to speak with or by submitting a written complaint to The Salvation Army Unit Director at the location you are being served. If you do not want your name, social security number, or date of birth entered in The Salvation Army Client Data Management System, tell the intake worker and circle the applicable section below. The Salvation Army will not refuse to help you for denying this. They will enter you into the system as an anonymous individual and keep your identifiable information separate. If applicable, circle this statement in italics: I am refusing to allow my identifiable information to be entered in The Salvation Army Client Data Management System and understand that my intake information will be entered as an anonymous client. I understand that my identifiable information will be stored separately in a secure database for anonymous clients. SIGNED CONSENT Each adult, emancipated minor, or unaccompanied youth must sign for him or herself. A parent/guardian should sign for children under the age of 18. My signature shows that I permit you to enter my personal information into a Client Data Management System. Print Name Client / / Date of Birth / / / / Signature of Client or Guardian Date Signed Signature of Witness Date Signed If applicable, dependent child under 18: Page 6 of 6 Revised 11/16/2016