Community Services Department Emergency Housing Assistance Application

Transcription

1 Application Instructions: Community Services Department Emergency Housing Assistance Application [ ] Did you call the Community Services Department and explain your situation? If not, you need to call option 4. If you did, continue to read and follow the instructions below. [ ] Have you applied for Emergency (Crisis) Assistance with the County? If you have applied for Emergency Assistance through the County, please send us proof of your approval or denial and submit it with this application. [ ] Collect proof of all the income your household had for the past three (3) months. This includes wages/paystubs, child support payments, disability payments, per capita payments, retirement payments, Social Security payments, General Assistance (GA), Minnesota Family Investment Program (MFIP) or Diversionary Work Program (DWP) payments. If anyone 18 or older did not have income in the past three months they need to provide a statement, signed and dated that they had no income. [ ] Provide written proof of your household s current housing emergency. This can be: a letter of past due rent, an eviction or foreclosure notice, a police report, or a third-party signed and dated statement verifying your situation. [ ] Provide a copy of your lease, rental agreement or mortgage statement. You can get this from your landlord or mortgage company. If you do not have a lease or a rental agreement with your landlord you can ask your landlord to provide you a written statement of your current agreement (what you pay per month, what is included in this amount, and how much you currently owe them). If you are currently homeless or searching for a new place to live: You will need to provide a copy of the new lease or rental agreement once the new place is found. [ ] Fill out the attached pages of the application completely. If you need assistance filling out the application, please contact us at option 4. [ ] Sign pages 2, 6, 7, 8, 9 and 10 of the application. There must be signatures from all persons over 18 years of age in the household in order for the application to be considered complete. [ ] Deliver, fax, or mail completed items to address below. You may want to call us one hour after faxing an application to make sure your application was received. What happens after you submit your application: 1. Your application is assigned to an Advocate that can best help in your situation. 2. An Advocate will review your application. If your application is incomplete or missing the requested information above, your Advocate will call you and send you an Information Request giving you 14 days to obtain the information and return it to Lakes & Pines. 3. You will be contacted to make a spending plan appointment with a staff person. You must complete this in order to receive financial assistance. 4. Your file will go to the Team Review Meeting, which is held every Wednesday. If your application is turned in on a Tuesday it will be reviewed by your Advocate, but will not have a financial assistance decision made until the following Wednesday. 5. Our first goal is to help you make your household and/or family stronger. This means we will offer helpful tips, information and ideas to everyone, but financial assistance will be determined on a case by case basis and will not be available for every applicant. We have various programs that help in various situations, so what works for one family might not work for another. We will also refer your household to other programs, such as the county. Each applicant should be ready and willing to apply for these programs Maple Ave East, Mora, MN Office & TDD FAX lap@lakesandpines.org Reasonable accommodations for people with disabilities upon request. An Equal Opportunity Employer/Contractor Serving the counties of Aitkin, Carlton, Chisago, Isanti, Kanabec, Mille Lacs and Pine Page 1 of 11

2 For Office Use only: New App Update Program (Prevention/Homeless) Household No. Address: City, State, Zip: Lakes & Pines' Community Services Department Emergency Housing Assistance Intake Form (Please complete all sections with your household information) Date: Date App Received: Date Housed: Last Name: First Name: Home Phone: ( ) Cell Phone: ( ) Type of Dwelling: House Mobile Home Townhouse Apartment Duplex Address: Type of Income Salary/Wages (for all 18 & over) Whose Income? (Initials) $ Unemployment $ Alimony/Child Support $ Workers Comp $ Social Security (Retirement) $ Disability (Private or VA) $ SSDI SSI $ Retirement/Pension $ $ General Assistance $ MSA $ Other Income $ MFIP/DWP $ No Income $ GROSS ANNUAL HOUSEHOLD INCOME (will be calculated by Advocate) $ Non-Cash Benefits (check all household receives) Household Information Food Assistance Medical Assistance WIC Employer/Private Pay Migrant Worker (Yes or No) Number of Persons in your household Medicare VA Medical Services Number of Employed Persons in your HH Minnesota Care Other (list) Interested in Head Start (Yes or No) Section 8 or other subsidized housing Anyone in household a veteran (Yes or No) Family Type (Check One) Female Single Parent Two Parent Family Couple with No Children Non-Custodial Caregivers Other Male Single Parent Is anyone in your household a Lakes & Pines employee or Board member? ( Yes or No) Client Signature: Date: Lakes and Pines Representative: List All Sources of Household Income for Persons over 18 Income (Indicate Amount and if (W)eekly, (B)iweekly or (M)onthly) Client Signature: Date: Type of Income County: Township: One Person Household Foster Parent Grandparents with Grandchildren Date: Emergency Phone: ( ) MI: Circle One: Own Rent Other Homeless In Shelter How long? Income (Indicate Amount and if (W)eekly, (B)i-weekly or (M)onthly) Whose Income? (Initials) Page 2 of 11

3 Last Name Lakes & Pines' Community Services Department Emergency Housing Assistance Intake Form-Page 1 First Name (Legal Name, no nick names) HOUSEHOLD MEMBER INFORMATION (Refer to Codes at Bottom of Page to complete.) Middle Initial Social Security Number Date of Birth (mm/dd/yy) Relationship to Head of Household Race Code Gender Code Disability Code Education Code Convictions F or M Hispanic Yes / No Medical Coverage Veteran Yes/No Registered Voter Yes / No Continue on additional sheets if more than 6 in household. Relationship to Head of Household Race Codes 1 = Self 1 = Black/African American 2 = Wife 2 - White 3 = Husband 3 = Asian 4 = Significant Other 4 = Asian & White 5 = Daughter 5 = Native American, Alaskan & White 6 = Son 6 = Native Alaskan 7 = Step-Daughter 7 = Native American 8 = Step-Son 8 = Native American, Alaskan & Black 9 = Mother 9 = Native Hawaiian 10 = Father 10 = Pacific Islander 11 = Grandmother 11 = African American/Black & White 12 = Grandfather 12 = Other Multi-Racial 13 = Granddaughter 13 = Other 14 = Grandson 15 = Other Relative Lakes & Pines Representative: 16 = Other Non-Relative HH Member 17 = Unknown Gender Code 1 = Male 2 = Female 3 = Transgender U = Unknown Office Use Only: Program Disability (Diagnosed) Code: Documentation may be required 1 = Alcohol Abuse 2 = Drug Abuse 3 = Mental Illness 4 = Dual Diagnosis 5 = Developmental Disability 6 = Physical/Mobility Limits 7 = Physical/Medical 8 = HIV/AIDS 9 = Vision Impaired 10 = Hearing Impaired 11 = Other Date: Date Status $ Amount Education Codes 0 = No schooling completed 1 = Pre-School 2 = 1st or 2nd Grade 3 = 3rd or 4th Grade 4 = 5th or 6th Grade 5 = 7th or 8th Grade 6-9th Grade 7 = 10th Grade 8 = 11th Grade 9 = 12th Grade, no diploma 10 = High School Diploma 11 = GED 12 = Some Post-Secondary School 13 = Vo-Tech Certificate 14 = 2 or 4 Year degree Convictions F = Felony M = Misdemeanor Page 3 of 11

4 Lakes & Pines Community Services Department Emergency Housing Assistance Application Health Insurance Household Member Name Covered by health insurance? Medicaid (MA) Medicare SCHIP (MN Care for Children) VA Medical Services Employerprovided COBRA Private Pay MN Care for Adults 1. Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No 2. Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No 3. Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No 4. Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No 5. Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No 6. Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Veteran Status Did client serve in the United States Armed Forces? (which includes the Army, Navy, Air Force, Marine Corps, and Coast Guard)? (18+ only) Yes No Did the client serve on Active Duty, or in the National Guard or Reserves? (18+ only) No Yes, Active Duty (regardless of Guard and Reserve answers) Yes, National Guard Yes, Reserves Both Guard and Reserves If yes to questions of either of the above, answer the following questions: If Guard or Reserve: Was client ever called to Active Duty as a member of the National Guard or as a Reservist? Yes No Did client enter Active Duty before 9/7/1980? Yes No For approximately how many months did client serve? What kind of discharge did client have? (# of months) Approximate answers OK Honorable or under honorable conditions Other than honorable, but not dishonorable Dishonorable Yes No Is client receiving VA disability pay? Page 4 of 11

5 Housing Status Extent of homelessness by Minnesota s definition on the day before program entry: Not currently homeless First time homeless AND less than one year without 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 Disability of Long Duration Does the client have a disability of long duration? (Adults only) Documentation is not required to answer Yes. Clients can answer Yes even if they have never been officially diagnosed with a disability Alcohol/drug abuse is considered a disability of long duration Adult Household Member Name Disability of Long Duration? 1. Yes No 2. Yes No 3. Yes No Foster Care Has the client ever been in foster care? (Youth 24 or younger) Youth Household Member Name Has been in foster care? 1. Yes No 2. Yes No 3. Yes No 4. Yes No Last Permanent Residence Length of Stay in prior residence How long since last permanent residence State of last permanent address County of last permanent address City of last permanent residence Page 5 of 11

6 Lakes & Pines Community Services Department Emergency Housing Assistance Application PERMANENT HOUSING PLAN AND GOALS Lakes & Pines emergency housing funds are limited and can only be used for housing emergencies to prevent homelessness or reduce a household s length of homelessness. To help assist you better, please answer the following: 1. Explain in detail what caused your current housing emergency. If you used money normally spent for housing costs to pay other unexpected bills you will need to provide proof of these paid bills along with your application. 2. Please list any issues that might keep you from being approved for a rental unit: criminal history, past unpaid rent, credit problems, etc.? 3. How much can you afford for monthly housing costs. These include rent or mortgage, utilities (heat, electric, sewer/water, garbage, possibly insurance and taxes). Typically, housing costs should be 30% to 50% of monthly take home income. 4. What steps have you taken to solve your housing emergency? Who, besides Lakes & Pines have you asked for help? 5. We will help you achieve goals to prevent future housing emergencies. What do you think needs to be worked on? a. b. c. 6. If Lakes and Pines can assist financially, it may be a limited amount. How much can you put towards solving your emergency? When will these dollars be available? Applicant Signature Co-Applicant Signature Date Date Page 6 of 11

7 Lakes & Pines Community Services Department Authorization to Release Information Printed Name of Applicant Date of Birth Printed Name of Co-Applicant Date of Birth (we) authorize the following entities to release and exchange information about me (us) and other household members for the purposes of verification and determining eligibility for program services (please check below). Releases are valid for one (1) year from the date you sign. [ ] Other Lakes and Pines departments [ ] County Family/Human Services [ ] County HRA (Section 8) office [ ] Financial Institutions [ ] Veterans Services Organization: Name: Phone: [ ] Mortgage Company Name: Phone: [ ] Credit Reporting Agencies [ ] Lutheran Social Services Financial/Budget Counseling [ ] Parole/Probation Officer Name: Phone: [ ] Employer: Name: Phone: [ ] MN Work Force Center and/or Employment Agencies [ ] Landlord Name: Phone: [ ] Motel Phone: [ ] Attorneys Name: Phone: [ ] Other: Applicant Signature Date Co-Applicant Signature Date Lakes & Pines CAC, Inc Maple Ave East, Mora, MN Office & TDD FAX Reasonable accommodations for people with disabilities upon request. Serving the counties of Aitkin, Carlton, Chisago, Isanti, Kanabec, Mille Lacs and Pine An Equal Opportunity Employer/Contractor Page 7 of 11

8 Minnesota's HMIS Data Privacy Notice & Consent to Enter Information Into HMIS We collect personal information about the people we serve in a computer system called Minnesota's HMIS (Homeless Management Information System). Many social service agencies use this computer system. Why? To help keep this program and others like it going. We are required to use HMIS. So we know how many people we serve and the types of people we serve at our agency and in the state. So we all understand what people need and can plan services to meet these needs. Who can see information that is in Minnesota's HMIS? People who work for this agency will use it to help provide services to you or your family. Auditors or funders who have legal rights to review the work of this agency, which may include representatives from the US Department of Housing and Urban Development or the State of Minnesota. Some people who work for Wilder Research (in St. Paul). Wilder runs Minnesota's HMIS. When Wilder works on the system, they may see information about you. Wilder may also use your information to conduct research related to homelessness and housing programs. Your name, social security number or other information that would identify you personally will not appear on a research report. People using HMIS information to write reports. Researchers must sign an agreement to protect your privacy before seeing HMIS information. Your identified information will never appear in research reports. The law says we have to report physical or sexual abuse of children and vulnerable adults. If we think there is abuse or neglect in your household, we will report it to Child or Adult Protection. We may release your information to protect the health or safety of you or others. Others, when we are required by law to provide information, including officials with a valid subpoena, warrant, or court order. We will not release your information for any other use unless you permit us, in writing. Your Rights If you do not want your name, social security number, or date of birth entered in HMIS, tell the intake worker. This agency will not refuse to help you for denying this. You have the right to a copy of the Minnesota's HMIS information about you. (Unless we cannot give it because of certain legal proceedings or for other lawful purposes.) You have the right to correct mistakes in HMIS information about you. If you think this agency or Minnesota's HMIS violated your privacy rights, you have the right to complain or appeal Ask a staff person for a complaint and appeal form. Or, write to Minnesota Coalition for the Homeless, HMIS Grievance, 2233 University Ave W, St Paul, MN Signed Consent To Enter Information Into HMIS Each adult and unaccompanied youth should sign for self. A parent/guardian should sign for children under 18. For: Date of birth: Print First and Last Name use back of page for children s names and birth dates My signature shows that I permit you to enter my personal information into Minnesota's HMIS. (You do not have to sign this form to receive services from this agency, but not sharing your information may affect the ability to quickly and appropriately identify services for you.) SIGNATURE OF CLIENT OR GUARDIAN DATE Signature of witness Date Minnesota's HMIS 01/08/15 Page 8 of 11

9 Minnesota's HMIS Release of Information For: Print First, Middle, and Last Name Date of Birth Please check a box: D DO NOT SHARE: I do not want any of the information about me in Minnesota's HMIS shared with any other service providers/homeless agencies. I understand that not sharing my information may affect the ability to quickly and appropriately identify services for me. (Data security= Closed) D SHARE: I (insert client's name), understand that Lakes and Pines, CAC. Inc. located at 1700 Maple Avenue East, Mora, MN is a partner agency in Minnesota's Homeless Management Information System ("HMIS"). I understand that there are many other partner agencies in Minnesota's HMIS. The agencies that participate in Minnesota's HMIS may change from time to time. A copy of the current list of agencies is available upon request. I authorize the information collected about me to be included in Minnesota's HMIS. I authorize the following information to be shared through Minnesota's HMIS, administered by the Wilder Foundation, located at St. Paul, MN, and for Minnesota's HMIS to share the information with other partner agencies in order to improve services to me and the services offered to others. Information that might be shared could relate to: Family/Household Information Name, date of birth, Social Security Number Services you receive Your income and income sources If you are homeless or not Reasons for seeking services Living situation and housing history Educational background and employment information Military history Health information, including physical health, HIV, behavioral health When you sign this form, it shows that you understand the following. We will not deny you help if you do not want us to share your personal information. If you permit us to share your data, this consent is valid until canceled by you. If you permit us to share your data, you may change your mind and cancel this consent at any time. If you cancel this consent, your data will not be shared except to the extent it has already been shared. If you consented to have your information entered into HMIS, but do not consent to have the information shared with other homeless providers or agencies, Wilder Research and the other limited people listed on the Notice & Consent to Enter Information into HMIS may see your information in HMIS, but the information will not be shared with other homeless providers or agencies. SIGNATURE OF CLIENT OR GUARDIAN DATE Signature of agency witness Date o Please treat information about my children age 17 or younger the same as mine. Minnesota's HMIS 01/08/15 Page 9 of 11

10 YOUR PRIVACY RIGHTS: THE TENNESSEN WARNING This sheet tells you about your rights under the Minnesota Government Data Practices Act. This act protects your privacy but also lets us give information about you to others if a law requires it and we tell you before we do it. This sheet tells why and when we will ask for and give information about you. Why do we ask for this information? We may ask you for information so we can: Tell you from other persons who have the same name or a similar name Decide if you are eligible to receive services from Lakes and Pines Assist you in getting medical, mental health, financial or social services from outside agencies Make reports, do research, audits and evaluate our programs Advocate for additional services as determined by your needs Do you have to answer the questions we ask? Generally the law does not say you have to give us information; however, without some of the information requested, we may not be able to find the appropriate help for you. Giving us incorrect information or not providing complete information may delay or eliminate some services you would be eligible for. With whom may we share the information we are requesting? The following are examples of agencies or organizations we may need to share information with on your behalf and are not intended to provide a complete list. This does not mean we always share information about you with these people or agencies. Social Services MN Housing Finance Agency Mental health centers Housing and Urban Development Veterans Services Organizations Community food shelves Child support workers Higher education facilities Medical facilities Court officials MN Department of Economic Security Hearth Connection MN Homeless Management Information System Anyone else to whom the law says we must provide MN Department of Human Services information MN Office of Economic Opportunity You have the right to copies of information about you: You may ask if we have any information about you. If we have information about you, you may ask for copies. You may have to pay for these copies. You may give other people written permission to see and have copies of private data about you. If you have any questions about the information, you may ask to have it explained to you. How do you appeal if you think information is not accurate or complete? Your objection must be in writing and must be sent to the Executive Director of Lakes and Pines CAC, Inc. at: Robert Benes, Executive Director Lakes and Pines CAC, Inc Maple Avenue E Mora, MN You may send your own explanation of the facts you disagree with. Your explanation will be attached any time that information is shared with another agency. For more information on how to do this, ask a staff member. If you have any questions about the information on this form, ask a staff person. I have read the above information and understand my rights. Signed: Date: Signed: Date: Page 10 of 11

11 Lakes & Pines' Community Services Department Emergency Housing Assistance Application Applicant Name: Co-Applicant Name: Monthly Budget Summary Complete the budget for the household you will be occupying. Not every line may apply to your household. Monthly Income Monthly Expense Summary Wages (take home) $ (Fill in totals from Monthly Expenses) Unemployment $ Housing $ MFIP $ Personal Expenses $ Child Support $ Loans/Credit $ General Assistance $ Vehicle/Transportation $ SSI $ SSDI $ Tribal per capita $ Food Support (EBT) $ Other: $ TOTAL $ TOTAL $ Monthly Expenses Housing Expenses Personal Expenses Rent/House Payment $ Food for Household $ Heat $ Eating Out $ Electricity $ Household Supplies $ Telephone/Cell Phone $ Clothing Purchases/Hair Cuts $ Water $ Education-Personal $ Trash $ Education-Children's Activities $ Cable/Internet $ Newspapers/Magazines $ Repairs/Maintenance $ Medical/Dental/Prescriptions $ Homeowners/Rental Insurance $ Laundry $ Property Taxes $ Gifts/Contributions/Dues $ Sub-Total $ Tobacco $ Pet Food/Care/Vet $ Child Support $ Loans/Credit $ Sub-Total $ School $ Personal $ Vehicle/Transportation Credit Cards $ Car Payment $ Other $ Gas $ Other $ Maintenance/Repairs $ Other $ Licensing/Insurance $ Sub-Total $ Sub-Total $ Page 11 of 11