Moving Forward Program Application

Transcription

1 Moving Forward Program Application Serving Umatilla, Morrow, Gilliam & Wheeler Counties Please make sure to complete all areas of this application! How do I turn in my application? You can drop of your application at our Pendleton office (721 SE 3rd St. Ste D), at our Hermiston office (1565 N First ST.,Sp. #1), or mail it to: CAPECO, 721 SE 3rd St. Ste D., Pendleton, OR After I ve turned in my application, what happens next? We will look over your application to figure out if your household appears to be eligible. If your application is missing information, we won t be able to process it. (If your application is missing information, we will try to contact you to get the information we need to finish your application). If you have questions or need help, please ask! The sooner we receive your finished application, the sooner you can be placed on the waiting list. The date/time your finished application is received at our office determines what your position is on the waiting list. CAPECO utilizes several different grants to provide rent subsidy through the Moving Forward Program The majority of our funds have three priority groups: households who meet HUD s definition of homeless, people with disabilities, and families with children. Please note that if your household doesn t fall into one of these priority groups, your wait time may be extended. After we have looked over your application, if you appear to be eligible, we will send you a letter in the mail letting you know that you are on the waiting list. If you appear to be ineligible, we may ask for more information and we will let you know why you are ineligible. (Please see the back of this page for information about requesting a hearing if you feel your application has been unjustly denied). While you are on the list, please let us know if your mailing address changes, if your income has significant changes, if your household members change, or if your housing situation changes. You can let us know by filling out a change of circumstance form. You can find that form on our website, or you can pick one up at our offices. While you are on the list, you may get occasional letters from us asking if you still want to be on the waiting list. (It is so important to open mail from us quickly! Please let us know if you mailing address changes!) You will need to respond to our letters within a certain amount of time to stay on the waiting list. What happens when I get to the top of the waiting list? When you reach the top of the list, you will get a letter from us letting you know. (It is so important to open mail from us quickly! Please let us know if your mailing address changes!) You will need to respond to our letters within a certain amount of time to be able to move forward. After we hear from you, we will ask you to complete a new application with updated information and we will invite you to an orientation meeting. 1 CAPECO is an Equal Opportunity Provider and Employer 721 SE 3rd St. Suite D, Pendleton, OR (541) * 1 (800) * (541) TTY Version-June 17

2 Hearing rights for the Moving Forward Program: If you disagree with the denial or limits of eligibility or of the termination or modification of benefits or other assistance awarded by CAPECO, you can request an informal review within thirty (30) days of the decision, by contacting CAPECO. A request for an informal review shall be personally presented, either orally or in writing so the grievance may be discussed informally and settled without a hearing. If you cannot settle the issue this way or you are still not satisfied you may request a hearing, in writing, to occur within thirty (30) days after the informal review. The Complainant will be provided with a copy of CAPECO s Formal Hearing Process. A Hearing Officer will arrange a date, time and place convenient to both you and CAPECO. In preparing for the hearing you have the right to examine any documents, including records and regulations that are directly relevant to the hearing. You have the right to be represented by counsel or other person chosen as your representative. You have the right to a private hearing unless you request a public hearing. You have the right to present evidence and arguments in support of your grievance and to controvert evidence. You also have the right to cross-examine all witnesses. The Hearings Officer must render a decision within ten (10) days of the hearing. The decision of the Hearings Officer will be final. 2

3 Please do not write in the gray box! Office use only. Date Stamp: Time: : Homeless Date incomplete letter sent Disability Children Under 50% AMI Under 30% AMI Date eligibility letter sent Month for 1st follow up Month for 2nd follow up Month for 3rd follow up Please use blue or black ink only Date: Name of Head of Household: Day phone #: Residence address: Mailing address (if different): How did you hear about us? Please tell us about your housing situation: As of today, I/my family are- Sleeping in a vehicle, camping or sleeping on the street Staying in a shelter (Warming Station, Domestic Violence Shelter, Martha s House, etc.) Living in our own rental unit Living in our own rental unit, but we are being evicted (72 hour notice, or through the courts) Other: If you are currently renting a home and you plan to stay in that home, please tell us: How much is your rent? $ Are you responsible for any utilities? Yes No How many bedrooms? If Yes, please circle: water sewer garbage natural gas electricity Water heater source: natural gas electric Heating system: natural gas electric other Is your housing safe and/or decent? Yes No Who is your Landlord? Phone #: Yes No Are you related by blood, marriage, adoption, or in a relationship with the Landlord of the rental unit you are seeking assistance? Yes No Do you have a rental/lease agreement? 3

4 Please tell us about who is in your household: Last Name First Name MI Sex Relationship to Head Head Date of birth Social Security Number Does anyone in your household have a disability? Yes Does your household have care provider expenses that allow a household member to attend school or work? Yes If yes, please tell us who (name): Does this person receive social security or veterans benefits for the disability? Yes Is anyone in your household a veteran? Yes If yes, please tell us who (name): If no longer on active duty, please list discharge status (honorable, dishonorable, etc): Is anyone in your household a full time student? Yes If yes, please tell us who (name) Is he/she under the age of 24? Yes Is he/she married? Yes Does he/she have dependent children? Yes Does anyone in your household have out-of pocket medical expenses not covered by insurance? Yes If yes, please tell us the monthly amount. $ Does anyone in your household have regular monthly prescription costs? Yes If yes, please tell us the monthly amount. $ Does your household have child-care expenses that allow a parent to attend school or work? Yes If yes, please list the family member(s) that childcare is provided for: 4

5 Hispanic? Prefer not to answer White Native Hawaiian/ Pacific Islander Asian Black/ African American American Indian/ Alaska Native What is your race/ethnicity? *Why do we ask this? HUD asks us to collect this information to make sure that laws that protect people from being discriminated against are followed. If you are uncomfortable sharing this information, please check prefer not to answer. Please check all that apply! Race: Ethnicity: Last Name First Name 5

6 Please tell us about your household s income: Please list all gross income (amount before taxes/deductions) for all members of your household (for example, these might include wages, social security benefits, TANF, child support, etc.). Who receives this income? (Name) What kind of income is it? How much do you receive? How often do you receive it? (Weekly, month, etc.) Please tell us about your resources: If you have MORE than $5,000 in assets, please do NOT sign. If you have LESS than $5,000 in assets, please sign below. By signing below, I/we certify that the total net family assets are under $5,000. If net family assets are over $5,000, do not sign here. I/We also understand that false statements or information are grounds for termination of housing assistance. What is an asset? An asset can be a number of things. Cash/savings, trusts, equity in property, stocks/ bonds, retirement or pension funds, cash value of life insurance, personal property for investment (like jewelry), inheritance, lottery winnings, etc. If you have questions, please ask! Signature (adult member) Date Signature (adult member) Date Signature (adult member) Date Signature (adult member) Date Do you have a checking account? Yes If you do, how much do you have in the account right now? $ Do you have a savings account? Yes If you do, how much do you have in the account right now? $ Do you have any stocks, bonds, real estate? Yes If you do, what is the current cash value? $ Do you have another agency helping you or other resources for housing right now? Yes If you do, please explain: 6

7 Are you or is anyone in your household related by blood, marriage, or adoption to any CAPECO employee or CAPECO Board Member? Yes No Are you or is anyone in your household living in the same household as a CAPECO employee or CAPECO Board Member? Yes No Have you or has anyone in your household ever been on the Moving Forward Program before? Yes No If yes, when (year)? By signing this form, I hereby authorize CAPECO to provide information to Oregon Housing and Community Services (OHCS). I further authorize OHCS and it s agents to access any records in order to verify information given. I consent to any legally authorized investigation for confirmation of any information that I provide. I agree to let the Department of Human Resources give information to OHCS or its agents, so I can receive assistance. I consent to have my Landlord share tenant records and other information with OHCS or its agents. If I receive assistance to which I am not entitled as a result of withholding information or knowingly giving fraudulent information, I must repay that assistance and may be found guilty of fraud and fined up to $10,000 or put in prison or both. I understand that no person may be denied assistance on the basis of race, color, sex, age, handicap, religion, national origin or political belief. I acknowledge that I have received the first page of this application outlining my rights to request a fair hearing if my application is unjustly denied. I further understand that I must request a hearing within thirty (30) days of the completed date of the application or date of denial. Signature (adult member) Date Signature (adult member) Date Signature (adult member) Date Signature (adult member) Date 7

8 Community Action Program East Central Oregon Authorization for Release of Information This form is optional! Do you have someone (not in your household) who is helping you, or are you working an agency/case worker who is helping you? If you do and you would like for us to be able to talk to that person/agency, please fill out this release of information. We will send duplicate letters to that person/agency when we send them to you. Please write in your family s information in this section: Adult name: D.O.B: SS#: Adult name: D.O.B: SS#: Adult name: D.O.B: SS#: Adult name: D.O.B: SS#: Children: I authorize the following individuals and/or agencies to provide information to CAPECO: Name of the person and/or agency you want for us to be able to speak to: The person/agency s contact phone number: The person/agency s contact address: Purpose: The information shared/received will be used to evaluate my situation/application and to plan for and coordinate services for me and my family. I agree that the agencies and individuals listed above may share and exchange information about my family and circumstances. YES NO This permission is good for one year or until: I can cancel this at any time but I understand that the cancellation will not affect any information that was already released before the cancellation. I understand that information about my case is confidential and protected by state and federal law. I approve the release of this information. I understand what this agreement means. I am signing on my own and have not been pressured to do so. Adult Member Signature Adult Member Signature Date Adult Member Signature Adult Member Signature Date To those receiving information under this authorization: This information disclosed to you is protected by state and federal law. You are not authorized to release it to any This 8 is a true copy of the original authorization document (Agency Staff Person)