SOUTH TEXAS HEROES HOUSING ASSISTANCE (STHHA) APPLICATION

Transcription

1 APPLICANT CO-APPLICANT Rental Emergency Asst. Utility Pmt. Supportive Services SOCIAL SECURITY NUMBER SOCIAL SECURITY NUMBER HA HP DV/SA RELOCATION EVICTION OTHER CURRENT ADDRESS APT OR LOT # TELEPHONE # ALTERNATE TELEPHONE # 30%AMI FEMALE VA BENEFITS/MEDICAL CITY TX ZIP CODE DEPOSITS SECURITY UTILITY CATEGORY WITH DEPENDENTS WITHOUT CHRONICALLY HOMELESS IRAQ AFGHANISTAN TOTAL HOUSEHOLD S, AGE, GENDER AND RELATIONSHIP INCLUDE ONLY THOSE PERSONS WHO WILL LIVE IN THE RENTAL UNIT TO INCLUDE THE APPLICANT, CO- APPLICANT, RELATED/UN-RELATED PERSONS. PROVIDE THE AGE, GENDER, AND RELATIONSHIP (TO THE APPLICANT) OF EACH PERSON WHO WILL RESIDE IN THE HOUSEHOLD WITH THE APPLICANT/CO-APPLICANT. DO NOT COUNT CHILDREN WHO ARE AWAY ATTENDING COLLEGE OR UNBORN CHILDREN. # AGE GENDER NAME First Name, Last Name 1. M F APPLICANT RELATIONSHIP HEAD OF HOUSEHOLD DOB EDUC. LEVEL, GRADE DISABLED VETERAN SOCIAL SECURITY # Y N Y N $ 2. M F Y N Y N $ 3. M F Y N Y N $ 4. M F Y N Y N $ 5. M F Y N Y N $ 6. M F Y N Y N $ 7. M F Y N Y N $ 8. M F Y N Y N $ 9. M F Y N Y N $ STAFF USE ONLY TOTAL ANTICIPATED GROSS ANNUAL INCOME OF ALL HOUSEHOLD S Add the amount of gross monthly income for each individual of the household and multiply by 12 to arrive at the gross annual income of the household. REFER TO THE APPLICABLE Income limit chart and circle THE CORRECT INCOME CATEGORY FOR THE HOUSEHOLD. HOUSEHOLD CHARACTERISTICS ETHNICITY AND RACE. THE FEDERAL GOVERNMENT REQUIRES THIS AGENCY TO COLLECT THE FOLLOWING INFORMATION FOR HOUSEHOLDS ASSISTED THROUGH THE STHHA, IN ORDER TO MONITOR PROGRAM COMPLIANCE. THIS INFORMATION WILL BE USED FOR STATISTICAL PURPOSES ONLY. ETHNICITY - PLEASE SELECT ONLY ONE (1) APPROPRIATE CATEGORY AS APPLICABLE TO THE HEAD OF HOUSEHOLD. HISPANIC OR LATINO NOT HISPANIC OR LATINO HEAD OF HOUSEHOLD TYPE RACE - PLEASE SELECT ONLY ONE (1) APPROPRIATE CATEGORY AS APPLICABLE TO THE HEAD OF HOUSEHOLD. 11 WHITE A PERSON HAVING ORIGINS IN ANY OF THE ORIGINAL PEOPLES OF EUROPE, NORTH AFRICA OR THE MIDDLE EAST. 12 BLACK/AFRICAN AMERICAN A PERSON HAVING ORIGINS IN ANY OF THE BLACK RACIAL GROUPS OF AFRICA 13 ASIAN A PERSON HAVING ORIGINS IN ANY OF THE ORIGINAL PEOPLES OF THE FAR EAST, SOUTHEAST ASIA, OR THE INDIAN SUBCONTINENT INCLUDING, CAMBODIA, CHINA, INDIA, JAPAN, KOREA, MALAYSIA, PAKISTAN, THE PHILIPPINE ISLAND, THAILAND AND VIETNAM. 14 AMERICAN INDIAN/ALASKA NATIVE A PERSON HAVING ORIGINS IN ANY OF THE ORIGINAL PEOPLES OF NORTH AND SOUTH AMERICA (INCLUDING CENTRAL AMERICA) AND WHO MAINTAINS AFFILIATION OR COMMUNITY ATTACHMENT. 15 NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER A PERSON HAVING ORIGINS IN ANY OF THE ORIGINAL PEOPLE OF HAWAII, GUAM, SAMOA OR OTHER PACIFIC ISLANDS. 16 AMERICAN INDIAN/ALASKA NATIVE & WHITE A PERSON HAVING THESE MULTIPLE RACE HERITAGES AS DEFINED ABOVE. 17 ASIAN & WHITE A PERSON HAVING THESE MULTIPLE RACE HERITAGES AS DEFINED ABOVE. 18 BLACK/AFRICAN AMERICAN & WHITE A PERSON HAVING THESE MULTIPLE RACE HERITAGES AS DEFINED ABOVE 19 AMERICAN INDIAN/ALASKA NATIVE & BLACK/AFRICAN AMERICAN - A PERSON HAVING THESE MULTIPLE RACE HERITAGES AS DEFINED ABOVE. 20 OTHER MULTI RACIAL OTHER MULTI-RACIAL HERITAGES NOT DEFINED AND INCLUDED IN ANY OF THE OTHER CATEGORIES LISTED ABOVE. GROSS MONTHLY INCOME (INDIVIDUALLY, FROM ALL SOURCES) $$ % AMI OF HOUSEHOLD DO YOU CURRENTLY RECEIVE GOVERNMENT HOUSING ASSISTANCE IF NO TO THE ABOVE, HAVE YOU APPLIED FOR HOUSING ASSISTANCE? IF YES, WHAT MONTH AND YEAR DID YOU APPLY? / PLEASE SELECT ONLY ONE (1) APPROPRIATE CATEGORY AS APPLICABLE TO THE HEAD OF HOUSEHOLD 1 SINGLE/NON-ELDERLY A ONE PERSON HOUSEHOLD IN WHICH THE PERSON IS NOT ELDERLY. 2 ELDERLY ONE OR TWO PERSON HOUSEHOLD WITH A PERSON AT LEAST 62 YEARS OF AGE. 3 RELATED/SINGLE PARENT A SINGLE PARENT HOUSEHOLD WITH A DEPENDENT CHILD(REN) 18 YEARS OLD OR YOUNGER. 4 RELATED/TWO PARENT A TWO PARENT HOUSEHOLD WITH A DEPENDENT CHILD(REN) 18 YEARS OLD OR YOUNGER. 5 OTHER ANY HOUSEHOLD NOT INCLUDED IN THE ABOVE DEFINITIONS, INCLUDING TWO OR MORE UNRELATED INDIVIDUALS. COORDINATOR: CONFIRMED HOUSING ON FILE DATE CONFIRMED: STAFF USE ONLY INITIALS: THE INFORMATION CONTAINED IN THE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT THIS IS AN AND DOES NOT GUARANTEE ASSISTANCE. APPLICANT SIGNATURE DATE CO-APPLICANT SIGNATURE DATE This program is supported by a grant from the Texas Veterans Commission Fund for Veterans Assistance. The Fund for Veterans Assistance provides grants to organizations serving veterans and their families. Page 1 of 5

2 HOUSEHOLD INCOME DISCLOSURE AND CERTIFICATION Enter the gross monthly amount for each household member who receives income TYPE INCOME APPLICANT CO-APPLICANT EMPLOYMENT / UNEMPOLYMENT OTHER HOUSEHOLD OTHER HOUSEHOLD OTHER HOUSEHOLD SOCIAL SECURITY / SSI or DISABILITY RETIREMENT/ PENSION/ SURVIVOR or DEATH BENEFITS CHILD SUPPORT / ALIMONY DIVIDENDS / ANNUITIES / MUTUAL FUNDS / INSURANCE POLICIES / IRA / 401K / STOCKS / BONDS/ TAXABLE INTEREST TANF/WIC/ FOOD STAMPS MONTHLY AMOUNT VA BENEFITS TOTAL MONTHLY INCOME BANK ACCOUNT INFORMATION ACCOUNT NUMBER BANK NAME BANK ADDRESS BALANCE List accounts for all household members EMPLOYMENT INFORMATION HOUSEHOLD NAME SUPERVISOR NAME EMPLOYER NAME EMPLOYER ADDRESS (Street Address, City, State, Zip Code) EMPLOYER TELEPHONE # WARNING: Title 18 U.S. Code 1001 states that a person is guilty of a FELONY for knowingly and willingly making a false or fraudulent statement to a Department or Agency of the United States. State law may also provide penalties for false or fraudulent statements. I certify that the information contained in this application is true and accurate to the best of my knowledge AND THAT Falsification of any documents, application or information provided will lead to my termination of participation with Families In Crisis, Inc. SSVF Program and could result in a Felony Offense. I also certify that I have disclosed ALL income received by persons in my household. Applicant Signature Date Co-Applicant Signature Date Page 2 of 5

3 ASSESSMENT *ANSWERING THESE QUESTIONS DOES NOT DETERMINE OR AFFECT YOUR ELIGIBILITY FOR ASSISTANCE 1. AT THE TIME OF PROGRAM ENTRY, WHAT WAS THE EXTENT OF THE CLIENT S HOMELESSNESS? NOT HOMELESS FIRST TIME HOMELESS AND LESS THAN ONE YEAR WITHOUT A HOME MULTIPLE TIMES HOMELESS, BUT NOT MEETING LONG-TERM HOMELESS DEFINITION LONG TERM: HOMELESS AT LEAST 1 YEAR OR AT LEAST 4 TIMES IN THE PAST 3 YEARS 2. HAD THE CLIENT LEFT ANY OF THE PLACES LISTED BELOW IN THE 90 DAYS BEFORE ENTERING THE PROGRAM? ADOPTIVE HOME DRUG OR ALCOHOL TREATMENT FACILITY JUVENILE DETENTION CENTER JAIL/PRISON MENTAL HEALTH TREATMENT FACILITY ORPHANAGE DV SHELTER RESIDENCE FOR PEOPLE WITH PHYSICAL DISABILITIES FOSTER HOME GROUP HOME HOMELESS SHELTER 3. LIVING SITUATION LAST NIGHT. WHERE DID THE CLIENT STAY LAST NIGHT BEFORE ENTERING THE PROGRAM? HOUSE/APT. RENTED BY CLIENT EMERGENCY SHELTER LIVING WITH FAMILY PERM. HOUSING FOR FORMERLY HOMELESS HOSPITAL PSYCHIATRIC HOSPITAL SUBSTANCE ABUSE TREATMENT LIVING WITH FRIENDS PLACE NOT MEANT FOR HABITATION FOSTER CARE/GROUP HOME JAIL, PRISON, OR JUVENILE FACILITY HOTEL/MOTEL TRANSITIONAL HOUSING FOR HOMELESS OTHER 4. LENGTH OF STAY: HOW LONG HAD THE CLIENT BEEN STAYING AT THAT PLACE? 1 WEEK OR LESS OVER 1 WEEK, LESS THAN 1 MONTH 1 TO 3 MONTHS OVER 3 MONTHS, LESS THAN 1 YEAR 1 YEAR OR LONGER 5. HOW LONG HAS IT BEEN SINCE THE CLIENT LIVED AT A PERMANENT ADDRESS? ZIP CODE OF THAT ADDRESS CURRENT ADDRESS 1 TO 3 MONTHS 3 TO 6 MONTHS 6 TO 12 MONTHS 1 TO 2 YEARS 3 TO 5 YEARS 6 TO 8 YEARS 9 OR MORE YEARS 6. PLEASE RECORD THE CLIENT S DISABILITIES BELOW: ALCOHOL ABUSE DRUG ABUSE HIV/AIDS MENTAL ILLNESS PTSD PHYSICAL DISABILITY TRAUMATIC BRAIN INJURY (TBI) OTHER DISABLING CONDITION: 7. TYPE OF MEDICAL COVERAGE: VA MEDICARE MEDICAID NONE PRIVATE ( ) I/WE CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE TO THE BEST OF MY/OUR KNOWLEDGE. I/WE HAVE PROVIDED ALL REQUESTED DOCUMENTATION REGARDING INCOME. I/WE ALSO UNDERSTAND THAT THIS IS AN FOR ASSISTANCE AND DOES NOT GUARANTEE FUNDING. ANY FALSIFICATION OF DOCUMENTS, OR INFORMATION PROVIDED WILL LEAD TO MY/OUR TERMINATION OF PARTICIPATION IN THE COMMUNITY ACTION CORPORATION OF SOUTH TEXAS, SOUTH TEXAS HEROES HOUSING ASSISTANCE (STHHA) PROGRAM. / / APPLICANT SIGNATURE DATE C0-APPLICANT SIGNATURE DATE Page 3 of 5

4 AUTHORIZATION FOR THE RELEASE OF INFORMATION EACH HOUSEHOLD OVER AGE 18 YEARS MUST COMPLETE THE FOLLOWING SECTION AND SIGN IN THE PRESENCE OF A NOTARY PUBLIC. PRINTED NAME OF HOUSEHOLD SOCIAL SECURITY # SIGNATURE DO HEREBY AUTHORIZE PERSONS, ORGANIZATIONS, OR EMPLOYERS, FEDERAL, STATE OR LOCAL AGENCIES, GOVERNMENTAL ENTITIES, UTILITY COMPANIES, RENTAL AGENCIES OR ESTABLISHMENTS TO FURNISH INFORMATION ABOUT MY/OUR HOUSEHOLD TO COMMUNITY ACTION CORPORATION OF SOUTH TEXAS IN CONJUNCTION WITH SOUTH TEXAS HEROES HOUSING ASSISTANCE (STHHA). I HEREBY GRANT PERMISSION FOR THE RELEASE OF INFORMATION THAT MAY BE RELEVANT TO MY/OUR ELIGIBILITY AND/OR THE OCCUPANCY OF AN ASSISTED UNIT. I UNDERSTAND THAT THIS RELEASE OF INFORMATION IS VALID FOR A MAXIMUM OF TWELVE (12) MONTHS OR UNTIL IT IS REVOKED IN WRITING. THE STATE OF TEXAS COUNTY OF Bee, Brooks, Duval, Jim Wells, San Patricio, Nueces, and or Kleberg THIS INSTRUMENT WAS ACKNOWLEDGED BEFORE ME ON THIS DAY OF, 20 BY,,. NOTARY SEAL NOTARY PUBLIC IN and FOR the STATE OF TEXAS Page 4 of 5

5 ASSISTANCE REQUEST Please describe the expenses you need assistance with. EXPENSE, SERVICE PROVIDER, ACCOUNT # $ AMOUNT DUE DATE 1. $ 2. $ 3. $ TOTAL $ REASON FOR FINANCIAL HARDSHIP Please describe what happened to cause your financial hardship. PLAN OF ACTION Please explain what plan of action you have taken to resolve this hardship on your own, other than applying for this assistance. / / Applicant Signature Date Co-Applicant Signature Date Page 5 of 5