Conference EFSP Application Checklist

Transcription

1 EFSP Application Checklist Client: Conference EFSP Application Checklist Please ensure that the following is complete before submitting for approval. Application page fully completed, dated and signed by client. Income/Expense Sheet and Plan of Action completed and included with application. Landlord Statement completed and attached. VESTA consent forms signed by all adults in household Worker s Assessment completed and attached. Household ID and Verification of Income have been verified by conference member. Once all of the above steps have been completed, , mail or bring all documents to: Karen Kearney St. Vincent de Paul Society 1125 Bank St. Cincinnati, OH X 227 kkearney@svdpcincinnati.org

2 SOCIETY OF SAINT VINCENT DE PAUL-CINCINNATI COUNCIL 2013 APPLICATION FOR EFSP RENTAL ASSISTANCE Last Name: First Name: Initial: Date: Address: Street Number Street Name Unit # City State Zip Code Address located within Hamilton County? Yes No Address located within Cincinnati City Limits? Yes No Phone #: Alt. Phone #: Social Security #: Birth date: Highest Grade Level: Marital Status: Race: Asian White Black/African American American Indian/Alaskan Native Native Hawaiian/Pacific Islander Ethnicity: Hispanic Non-Hispanic Employed? Yes (Full-Time Part-Time Temp Work) No Do you have a medical home or primary care doctor? Yes No Disabled Retired If yes, please list name of practice or doctor: Other Household Members: Name D.O.B. Relationship to Applicant Entire Social Security Number Highest Grade Level Completed Veteran? Reason for Financial Problem: 1. Lost Job Circle Current Status: Looking for New Job New Job Lined Up Awaiting Unemployment Description: 2. Temporarily Off Work for Health Reasons Circle One: Illness Work-Related Accident Maternity Other Description: 3. Awaiting Benefits (Not Unemployment) Please Specify Type(s) of Benefit: Description: 4. Unexpected Emergency Expense (Car Repair, Death or Illness in Family, etc.) Description: 5. Other Description: How will you pay your rent next month? SVDP/EFSP Note: Complete only part 1 or part 2 of the next two sections:

3 Part 1 If you are applying for help with rent for your present apartment complete the following: What is the cost of your rent per month? $ If you are now behind in rental payment, how much do you owe (not including late fees) $ Do you owe Late Fees? If Yes, please state amount: $ Total amount Owed: $ Amount your landlord will require you to pay to remain in your apartment for 30 days: $ How much can you pay toward this amount? $ Amount you are requesting (this figure should not exceed one month s rent): $ Part 2 If you are applying for first month s rent in a new apartment: Describe your current living situation including whether it is an apartment, shelter, vacant building, etc., how long you can stay there, when you began living there, etc. What will your first month s rent be? How much of that can you pay? $ $ How much assistance are you requesting for your first month s rent? $ If there is a security deposit, please state the amount: $ How will you pay the security deposit? ALL APPLICANTS COMPLETE THE FOLLOWING: Name of Landlord: Phone Number: Address and Zip Code: Fax: SERVICE AGREEMENT AND RELEASE OF INFORMATION: By signing this form I certify the accuracy of the above information and formally request Emergency Food and Shelter Program or Weathering the Economic Storm ASSISTANCE. I authorize my employer, the Department of Job and Family Services and other organizations or individuals who are providing assistance to me to release information as may be necessary to verify this application within 30 days of the date below. I understand that my landlord will need to provide an affidavit substantiating the regular monthly amount of my rent payment exclusive of any other fees or charges and guarantee that I can remain in my residence for additional 30 days if payment is made. In addition, I give my permission for the Cincinnati Council of the Society of St. Vincent de Paul to share this information in any way specified by the United Way of the Greater Cincinnati Area and/or Weathering the Economic Storm for the purpose of processing my application and preventing duplication of service. I have read the above paragraph and fully understand it. APPLICANT S SIGNATURE DATE: SVDP/EFSP

4 Society of St. Vincent de Paul Income/ Expense Worksheet for: Date Instructions: Put what you think you will spend on left (projected). Monitor your expenses for the month and put what you actually spent on the line to the right. Income Projected (monthly) Actual Employment Self $ Spouse $ Other adult $ Food Stamps $ OWF (welfare) $ SSI/SSD $ Others SSI/SSD $ Child Support $ Unemployment $ Workers Comp $ Social Security $ Others SS $ Other Income $ Total $ Difference between Income and Expenses +/- $ Expenses Projected(monthly) Actual Rent $ Utilities $ Food $ Auto loan payment $ Car Insurance $ Gas/Bus Fare $ Health Insurance $ Laundry $ Telephone $ Household products $ Child Care $ Child Support $ Clothing $ Credit Card Payment $ Other Loan Payment $ Cable/Internet $ Savings $ Entertainment $ Other $ Other $ Other $ Total $ Your Plan of Action: Consider how to increase your monthly income, and/or decrease you household expenses. Examples include reducing or cancelling non-essential expenses, receiving credit counseling, increasing employment or self employment income, adjusting transportation expenses, moving to less expensive housing, applying for housing or energy assistance or welfare benefits. Please list changes you will commit to. What you will do to increase income: What you will do to decrease spending: What other budgeting actions you will take to reach your goal: Client Signature Date SVDP/EFSP

5 Cincinnati District Council nn Charitable Pharmacy of Cincinnati. Inc. t St.Vincent de Paul 1125 Bank Street. Oncinnati, OH Phone: (513) Fax: (5t3) RENTIMORTGAGE DOCUMENTATION NeightJors helping neighbors~ Client Information: Client Name: Client Address: Date (month/day/year): (complete street address) (city/state/zip) TVI}eof Assistance: Rent (check olle) Mortgage (check olle) D Past due rent D Past due mortgage D Current month's rent D Current month's mortgage o First month's rent (effective/move in date ) (month/day/year) The monthly rent/mortgage payment is $ The total owed (including the amount above) is $ The one month amount being paid by this agency is $ The amount being paid is for the month of (month/years The one month amount being paid is/was due on imonth/day/yearv The one month amount being paid is past due in its entirety at time of payment (check one): DYes DNo LHO Verilication (To be completed bv the LHO stafo: LRO Staff Name: ---,- LRO Staff Signature: Date tmonth/day/yeary: Landlord/Mortgage Holder Verilication (To be completed by the landlord/mortgage holder): This is to confirm that rent/mortgage for ---,-: for the property (name of individual or family) at :--:---:-: : : with (complete address, street number and name, city, state, zip code) a monthly rent amount of $ (rent only: includes no deposits, late fees, or other charges) or with a mo. tgage with a monthly payment of $ (principal and interest only; 110 escrolv payments or other fees) is/was due on. The total amount currently owed is $ The individual! (month/day/year) family now has rent/mortgage due/past due for the month(s) of -,--,-,---- (month/year) Important: Payment will guarantee residency for an additional 30 days! 80

6 2013 EFSP WORKER S ASSESSMENT (PLEASE TYPE OR PRINT) SVDP Conference (Parish) Vincentian s Name: Vincentian s Vincentian s Phone Client Name: Date of Office/Home Visit:, 2013 Interview Results: Supports Need for Assistance with Rent/Mortgage: Yes No Supports Ability of Applicant to Meet Next Month s Expense: Yes No Explain: COMMENTS State your understanding of the reason the applicant needs assistance with rent. Also describe any other factor in the client s life that you feel might be contributing to the current financial problem. List strengths you observed that help him/her avoid problems when possible and deal effectively with them otherwise. Does your assessment indicate that a lack of financial management skills or understanding contributed to the client s current financial problem? Yes No Referral (if applicable) Could it be expected that without intervention, the cause of the problem (other than financial mismanagement) will be repeated? Yes No Referral (if applicable) Note: Our goal is to help each applicant maintain stable housing. Please consider referrals to help your client address underlying causes of financial instability. Do you recommend providing EFSP assistance with rent? Yes Amount: $ (Please double check this amount to ensure that it has been determined with consideration of what the client is able to pay him/herself client s partial contribution to the overall amount is strongly encouraged.) No Please attach a statement signed by the client agreeing to carry out any conditions you felt were necessary in order to recommend this assistance.