Bell County H.E.L.P. Center Financial Assistance Crisis Intervention Screening Form

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Catherine Watson
5 years ago
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$First, Middle & any oilier last name used: Date of Birth: \l»: I' N: pouse or ignificant other's name: Date of Birth: N: o P.O. Box) What is your marital status?$

1 Bell County H.E.L.P. Center Financial Assistance Crisis Intervention creening Form s _Fill in all blocks. Put N/A if does not aoolv to household j Name: Last. First, Middle & any oilier last name used: Date of Birth: \l»: I' N: pouse or ignificant other's name: Date of Birth: N: o P.O. Box) What is your marital status? Married ingle Divorced eparated Are you or anyone in your famely/household associated with the military? Y N Are you a Veteran or surviving spouse jf a veteran? Y N Home: Citv: Zip: Work: Cell: Are you and your spouse employed? Full-time Part-time elf: Y N By whom: pouse: Y N By whom: Are you registered with TWC? Y N Is your significant other registered with TWC? Y N Have you received assistance from Killeen or Temple H.E.L.P. Center Y N Do you normally earn enough to keep up with your bills? Y N Have you applied for assistance rom any other agencies? Y V f yes, where? Please list all people who live in the home include yourself. tart with the oldest to the youngest (Please Print) NametLast, First, Middle) Relationship Date.if Birth ex Race U.. Citizen Yes No [.egul Alien Yes No In chool Yes No ocial ecurity Number TYPE OF AITANCE NEEDED: Name of company you need assistance with: Explain your UNEXPECTED crisis that is preventing you from meeting your financial obligations. Thorough xplanation required: Note: Approved Denied History ordered For Caseworker Only: Electric Water Rent Transportation Prescription Gas ''I A P P 1

$Center Financial Assistance Crisis Intervention creening Form Wages-elf Monthly Income (+) If an item does not pertain to your household put \ Wages- pouse l/d/v A/Retirement TANF Other Household$

2 Bell County H.E.L.P. Center Financial Assistance Crisis Intervention creening Form Wages-elf Monthly Income (+) If an item does not pertain to your household put \ Wages- pouse l/d/v A/Retirement TANF Other Household Member Unemployment Outside assistance (Friends, relative, etc) From Whom? Rent(what you pay) Groceries Child Care Transportation(Car Payment) Child upport Educational Pell Grant Housing Assistance Utility Check (HUD) Food tamps Total Household Income Monthly Expenses (-) If an item does not pertain to your household put N/d Electric(Extension/Terminat Gas Water Total: ion Cable Phone Medication Total: Child upport Loans Insurance (Car, Life, Health) Total: Gasoline Credit Card Please complete ONLY what applies to your request: Pertinent Information For utility assistance; Other Total: Utility account*: Utility Comoanv: Amount Due: What name is on the account? Password/Code: What period of time does this bi 1 cover? How much can you pay on this t)ill? Have arrangements been made with Co. Y Has the deposit been paid Y For Rental Assistance N N Name/address of landlord: much of the rent can you pay at Is there and eviction notice? Y On section 8 housing: Y N Phone his time? N If yes, date you must be out of residence: If ves. customer amount to oav monthly: Check if request applies to you; Amount due: How Work related items: Work boots ID card Medication: Child Care: Birth Certificate Other/pecify Referred by Health Card Other/pecify Agencv: elf: Friend: Relative: List any other agencies that you have applied with assistance for your bills: I am in need of assistance listed above and I declare to the best of my knowledge that all of the above information is true and correct. I do hereby authorize the H.E.L.P Center personnel to release and/or obtain information concerning my case to the Local, tate, and Federal Government and other interested parties in our service area. I realize that I may be liable for prosecution or denied services for falsifying the above information. Printed Name ignature Date

Employment email address. List your last two employers: tart with Present employer If you have never worked put N/A elf! 1. Employer tart Date End Date upervisors name 2.

3 Employment address. List your last two employers: tart with Present employer If you have never worked put N/A elf! 1. Employer tart Date End Date upervisors name 2. Employer tart Date End Date upervisors name pouse/ignificant othei 1. Employer tart Date End Date upervisors name i 1 2. Employer tart Date End Date upervisors name,,, 1 1 Other household members 1. Employer tart Date End Date upervisors name

4 Applicant's additional comments: Caseworker's notes: Documents a I.D. Card a pouse I.D. Card a Food tamp Printout, TANF award letter a All ocial ecurity Cards a Birth Certificates (children) a Pay tubs Income: Work, VA, ocial ecurity, Unemployment, Etc. a Current Bills: Electric, water, cable, phone, car, rent, gas, medical, all expenses a Current Receipts of bills a HUD Paperwork -) Lease -3 Original electric if helping with electric (must be in clients name) Comments pertaining to documentation:

r Bell County Human ervice Killeen 201 East Ave. D, Killeen, TX 76541 Ph 254-519-3360 Fax 254-519-3369 AUTHORIZATION TO RELEAE & OBTAIN INFORMATION Applicant _and 4 pouse living at.

5 r Bell County Human ervice Killeen 201 East Ave. D, Killeen, TX Ph Fax AUTHORIZATION TO RELEAE & OBTAIN INFORMATION Applicant _and 4 pouse living at. treet Address City tate Zip do hereby authorize persons, organizations, or establishments having information or records concerning me/us (or) circumstances to furnish such information to a representative of the Bell County Human ervices. I understand that this information will be requested only as needed to make an eligibility determination for my financial assistance request. I hereby grant permission for the Bell County Human ervices to obtain and /or to release information that may have a bearing on my/our eligibility for family support services or for other human service agencies, churches, and organizations that I may be referred to. This may include information about my/our medical status, resource status, income status, and household composition, as well as status of pending, active or closed applications/cases for other forms of assistance such as: ocial ecurity Disability, I (upplemental ecurity Income), Medicaid, TANF (Temporary Aid to Needy Families), Food tamps, TRC (Texas Rehabilitation Commission), TCB (Texas Commission for the Blind), Community Food Banks/Pantries, alvation Army, t. Vincent de Paul, ection 8/HUD, Housing Authority, Home & Hope helter, FIC (Families In Crisis), Martha's Kitchen, the Bell County Health District, the MHMR system, Faith Base Organizations, and other community assistance agencies/programs. I understand that this release is valid fora period of (2) years from the date of signature unless I revoke it in writing prior to that date. ignature Date ignature of pouse Date Information Release

6 Bell County H.E.L.P. Center Guidelines & Rules Our primary mission is to provide assistance in developing individual plans and/or proper referrals to other agencies to support heads of households in attaining maximum sufficiency for themselves and their families. ALL clients will be required to attend self-sufficient education classes PRIOR to receiving financial assistance. Families that experience a recent layoff, life threatening illness, or sudden reduction in household income due to unforeseen circumstances will have priority. In all cases the bills must be in the applicants name and only current bills (within the past 30 days) will be taken into consideration. Only one customer from the same household may apply for assistance. Completion of the application and Orientation does NOT guarantee assistance will be provided. Cases approved or disapproved will be at the discretion of the caseworker. **ALL FINANCIAL AITANCE WILL BE BAED ON THE AVAILABILITY OF FUND.** Financial Assistance Programs 1. Prescription (no pain medication or chronic illness medication) 2 Utilities & Rent a. NO disconnect and reconnect fees, deposits, down payments, late fees, tampering fees, bounced check fees, transfer fees, and any other miscellaneous fees/penalties. b. Once utilities are shut off, the account is closed, and/or a client is evicted from their place of residence, financial assistance cannot be applied to their accounts 3. Transportation (Bus Tokens or Bus Passes) 4. Texas tate ID's, Driver Licenses, and Birth Certificates. 5. Education: GED, Tuition, Books, Licenses, & Certifications. Ii you have any concerns or complaints about the service you've received regarding your case you may coll our main line in Killeen at (254) or send a written complaint to: Bell Count)' Killeen H.E.LP. Center 201 East Avenue D Killeen, TX Non - Emergency Crisis The H.E.L.P. Center does not consider the following circumstances an emergency that warrants financial assistance. 1. Termination of utility /fuel service due to financial mismanagement or tampering. 2. Eviction notice due to violation of lease to include destruction, poor maintenance of property, or financial mismanagement. 3. Low-income households that receives the three basic assistance services of HUD or Housing Authority, Food tamps, and TANF.. 4. Loss of Housing Assistance due to non-compliance with HUD or Housing Authority. 5. Refusal or neglect of household to apply for program previously referred to by staff or other agency staff. Must have verification of denial or approval required, (i.e. referrals to the Free Clinic, Medicaid, Food tamps, TANF, etc.) 6. Loss of employment due to inappropriate work behaviors, (i.e. Fired, work violations, absentee's or tardiness). Client Guidelines for Assistance It takes our staff approximately 3 to 4 business days to process an application. (This is just an estimate, sometimes it might take longer depending on certain circumstances). ALL documentation is required in order to receive assistance. If you are missing documentation at the time of your appointment it is at the discretion of your assigned caseworker to reschedule or deny your case. Children are not allowed in the appointment. You MUT be on time. If you are late it is at the discretion of your caseworker if you will be rescheduled an appointment or if your case will be denied. It is your responsibility to pay for any portion of the bill that we cannot assist you with. Please make sure that you keep your receipts to show your caseworker during your appointment. The guidelines above have been explained to me and 1 have been given a copy of these guidelines in Orientation. I understand and agree to follow these guidelines. I also understand that if 1 do not follow these guidelines or comply with the rules and regulations of the Bell Count)' H.E.LP. Center that I might be disqualified or denied from receiving assistance. ignature Date

Bell County H.E.L.P. Center 201 East Ave. D Killeen, TX 76541 Appointment Notice You must bring all required documentation in order for your application to be processed.

7 Bell County H.E.L.P. Center 201 East Ave. D Killeen, TX Appointment Notice You must bring all required documentation in order for your application to be processed. We will NOT be able to assist you if you do not have all verification at the time of the appointment. Children are not allowed to attend classes or appointments. What to bring with you to your appointment: Proof of Identity: -wial ecurity Cards for all household members. -Valid Texas picture IDs (tate IDs or Driver License) for all the adults (18+ ) in the household. -Birth Certificates for the children in the household. Proof of Residence -Copy of your lease -Your lease should include the name, address, and phone number of your landlord. - Uhlitv bill for homeowners Proof of Earned Income or Wages -Bring proof of income for the last 30 days (check stub, copy of checks, letter from your employer, etc.) -"If Unemployed, must bring in proof of registration with TWC.** Proof of Unearned Income -Award Letters stating monthly benefits tor: TANF, Fixxl tamp, ocial ecurity, I, DI, V'A Benefits, Unemployment Benefits, Retirement Pensioa HUD/ection 8, Child upport, divorce settlement payments, etc. Proof of Current Monthly Bills -MUT BRING CURRENT UTILITY BILL! Receipts, Invoices, Monthly tatements, and/or E-Bill printouts (no screenshots). "Verification about what has happened within the past 60 days, which has caused an EMERGENCY OR CRII." Proof of Expenses Causing Loss of Income -Receipts, invoices, pharmacy payments, doctor's bills, divorce decree, emergency repair work, bank statements, etc. Traiga lo siguiente para su cita: Prueba de Identidad -Trajeta de eguro ocial de todos los miembros del hogar. -Valido foto de idenufcacion de Tejas (identifcadores de Estado o Licencia de Conducir) para todos los adultos (18+) en el hogar. -Certificados Je natirruento para los ninos en el hogar. Prueba de Residencia -Copia de su contrato de arrendarruento -u contrato de arrendamiento debe incluir el nombre, direccion y numero de telefono de su propetano. -Factura de serviaos publicos para los propnetarios Prueba de Ingreso o alario Traiga prueba de ingresos para los ultimos 30 dias (talon de cheque, copia de cheques, carta de su empleador, etc.) -** i no esta trabajando/ debe traer el comprobante de inscripcion con TWC." Prueba de Ingresos no Derivados del Trabajo -Premio Cartas indicando prestaciones mensuales por: TANF, Estampillas para Comida, eguro ocial, I, DI, beneficios de VA, benehaos de Desempleo, pension de jubilacion, HUD/eccion 8, manutencion de los hijos, pagos de liquidacion de divorcio, etc. La Prueba de la Actual Facturas Mensuales -DEVE LLEVAR CLIENT A CORRIENTE DE UTIUDAD! Recibos, facrures, estados de cuenta mensuales, y/o impresos E-Bill (sin capturas de pantalla). **Verificacion sobre lo que ha sucedido en los ultimos 60 dias, lo que ha provocado un de EMERGENCIA O CRII.** Prueba de Gastos Causando Peridida de Ingresos Los red bos, facrures, pagos de farmacia, medico proyectos de ley, decreto de divorcio, el tiabajo, de reparation de emergencia, estados de cuenta bacanos, etc. Orientation Name: TUEDAY 9:45am - 12:30pm Date: WEDNEDAY am - ll:30am Date: You MUT stay for the entire Orientation in order to get an appointment with a caseworker. NO EXCEPTION. Be here 10 minutes early. Doors will close promptly once Orientation begins. If you are late you will need to reschedule for the next available Orientation. Bring the CURRENT bill you are requesting assistance for. No children allowed. NO EXCEPTION Bring a pen to write with. BLACK ONLY Bell County Human ervices H.E.L.P. Center - Killeen

Rx for Oklahoma P.O. Box 603 Jay, OK Phone: ext 34 or 29 Fax:

Rx for Oklahoma P.O. Box 603 Jay, OK 74346 Phone: 918-253-4683 ext 34 or 29 Fax: 918-253-6059 Email: lindaely@neocaa.org Email: lrutherford@neocaa.org Serving Craig, Delaware and Ottawa Counties Thank