EOAC. Community Programming 500 Franklin Waco, TX THIS IS NOT AN ENTITLEMENT PROGRAM.

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1 EOAC Community Programming 500 Franklin Waco, TX THIS IS NOT AN ENTITLEMENT PROGRAM. Applications will NOT be processed unless All information is provided by client. Please pay close attention to the list of required documents below. Incomplete information will result in loss of your place in the processing. No mailing, drop off, faxing, or ing of ANY PAPERWORK. Income for the last 30 days if applicable to your entire household: All income must be dated within the last 30 (thirty) days from day of interview (including income for date of interview). Award letters must show 2015 benefits. Employment Check Stubs Social Security Award Letter Child support printout Disability Award Letter TANF/Food Stamp Award Letter Pension Letter Retirement Letter Unemployment Printout Workers Comp. Letter Veterans Award Letter Self Employment form Teachers Retirement Letter Declaration of Income with notarized form Student Financial Aid Printout Housing Utility Assistance Check stub All Other Household Income Social Security Number and Date of Birth for Everyone in the Household. 12 MONTH or however long you have been with your Utilities Company billing history for your gas, electric and propane utility bills. (This can be obtained from your electric, propane or gas company.) Electric Gas Propane Utility Bill - Must provide a copy of each bill even if not requesting payment. Current Electric Bill Current Gas bill Current Propane bill Complete attached Application packet and LEAVE NO BLANKS before interview. We are unable to assist with Pay-As-You-Go or Prepaid Utilities. All financial assistance is made based upon Federal Guidelines and Regulations of Poverty and Documentation Need. All assistance is subject to the Availability of Funds. Funding is not guaranteed. Clients are responsible to pay their portion of the bills and any/all fees/deposits occurred. Revised

2 EOAC Community Program Utility Assistance Comprehensive Energy Assistance Program (CEAP) General CEAP Assistance: 1. Must be within 125% of poverty level. (Gross income) 2. Only 1 bill may be submitted within the month 3. Must be living in the home for which you are applying for assistance. 4. Applications are good for one calendar year (Jan through Dec). 5. Utility company must have a vendor agreement with us. 6. If the vendor that you use does not have an agreement with us, you may request that the Director of Community Programming send the forms to the vendor for approval. 7. Client must provide the previous 30 days proof of income including the date of the interview for all household members. (No bank statements or HHSC award letter will be accepted.) 8. If anyone in the household has no income: the Statement of no Documented Proof of Income needs to be notarized before the interview; and they must register for employment with Work in Texas (TWC) at 9. If utilities are completely shut off you, will need to contact your utility company to determine if there are fees or deposit due. (EOAC cannot pay fees or deposits on accounts) 10. Utility account must be active and not a closed account in order to receive assistance. 11. Must provide a copy of each bill even if not requesting payment. Current Electric Bill, Current Gas bill/propane bill. 12. EOAC does not make extensions on utility bills. 13. We are limited to the funding that is provided to us by the Texas Department of Housing and Community Affairs (TDHCA). 14. We have two funding programs that we can assist clients from with a maximum amount for each: Household Crisis Program-AS long as funding is available Eligible amounts range from 1,000 to 1,200 per calendar year. (EOAC cannot guarantee all payments if funds are exhausted.) Client is in a crisis situation (Utility cut off) Disconnection notice (Limited to 2 per year) Under Weather Related Crisis - during the usage cycle - three or more days: 95 degrees or higher for the cooling season and 32 degrees or lower for the heating season. Must have the current utility bill (if applicable). Utility Assistance Program-AS long as funding is available Eligible amounts range from 1,000 to 1,200 with 6 or 8 payments per calendar year. We ask that the client bring in a 12 month Billing History (or for the length of time they have been with their utility company) at the time of their first visit. If they have been with the utility company for 12 months we can assist you based on the usage cost (payment minus deposit and fees) from last year s Billing History for future payments. No future appointments needed. You will not be eligible for any additional payments during the months that payments are set up for you during the year. (Payments based on last year usage and not this year s bill) If you have not been with the utility company for 12 months you will have to bring your current bill each month for your future payments EOAC has the right to change or amend information listed. All financial assistance is made based upon Federal Guidelines and Regulations of Poverty and Documentation Need. All assistance is subject to the availability of Funds. Funding is not guaranteed. Clients are responsible to pay their portion of bills and any/all fees/deposits occurred. I have read and understand the above information. Signature of Client Date Revised

3 EOAC COMMUNITY PROGRAMMING CLIENT INTAKE Client File # Part I Name: (First) (Last) (M.I.) County: Residence Address: Mailing Address: (Street) (apt. #) (City) (Zip) (Street) (apt. #) (City) (Zip) Phone #/ (Home) (Work) (Cell) ( ) Part II Give the following information about each household member, including yourself. Name Date of Birth Sex SSN Race- White/Black/ Asian/Indian/ MuliRace/ Other Hispanic Disabled Veteran Heath Insurance or Medicaid Education- Highest Grade completed 1

4 EOAC COMMUNITY PROGRAMMING CLIENT INTAKE Part III List all income for household members. Source of Household Income for Previous 30 days (including income for the date of interview) Name Name Name Name Name Alimony Child Support Dividends/rental Income Employment/Wages Food Stamps Student Financial Aid Private Pensions Teachers Retirement Regular Insurance/annuity payments Retirement Benefits Social Security Social Sec Disability Income (SSDI) Supplemental Social Security (SSI) TANF Self Employment Unemployment Compensation Veteran's Benefits Workman's Compensation Other: (explain) No Income IV Is anyone in the household an EOAC Employee or EOAC Board Member? Yes No If yes, a signed letter from EOAC Executive Director must accompany application prior to service being given. 2

5 EOAC COMMUNITY PROGRAMMING CLIENT INTAKE V Complete the following information for your household Household Type: Check One: Other Characteristics Check One: Single Parent/Female Single Parent/Male Two-Parent Household Farmer Migrant Farmer Seasonal Farmer Single Person Two Adults-No Children Other Housing Own Home Monthly Amount Rent Home Household Size Check One: Homeless 1 Public Housing 2 Section 8 Housing or More Information on Landlord: Name: Address City/State/Zip Phone Number Has your home been Weatherized by EOAC Weatherization Program? Yes When: No 3

6 EOAC COMMUNITY PROGRAMMING CLIENT INTAKE VI How does the family pay for heating and Cooling? To Utility Company To Landlord/Manager Included in Rent What is the main way you cool your home? Central Unit Window Units Evaporative Cooler None Check One: Check One: What is the main way you heat your home? Space Heater Wall Furnace Electric Heater Fireplace Cook Stove Wood Burning Stove Central Heat Other None All Utility Providers and Account Numbers for the Household must be listed. (Include even if assistance is not required at interview) Indicate "N/A" if Utility is not used in your home. Name of Vendor Electric Service Provider: Natural Gas Provider: Propane Company Provider: Account Number Name of Vendor Account Number Name of Vendor Account Number Heat Cool Heat Cool Heat Cool Future assistance cannot be provided for any utility account that is not listed at the time of interview Part VII CERTIFCATION (APPLICANTS MUST SIGN THIS SECTION) I certify that the information provided on this application is true and correct to the best of my knowledge and belief. I understand that any falsification could result in my case closed and request for repayment. (Applicant Signature) (Date) 4

7 EOAC COMMUNITY PROGRAMMING NEEDS ASSESSMENT Basic Needs: Food, Clothing, Food Stamps, WIC, Meals on Wheels, etc. Income (Government Assistance): RSDI, TANF, SS, SSI, VA, Wages, other Transportation: To work, Doctor appointment, other Utility Assistance: Gas, Propane, Water, Electric, other Heating/Cooling: Appliances: None in house, not working properly, other Housing Needs: Temporary Shelter, Low income housing, Rent assistance, Weatherization, Repairs, other Child Care, Elderly Care, other Education: GED, English as a Second Language, Vocation/Tech training, other Employment: Looking for a job, job search assistance, resume, other Veterans Needs: Medical, Training, other Legal Needs: SERVICE Child Support, Criminal, Civil, other Health Needs: Immunizations, Medication, Mental Health Services, other Counseling: Family, Alcohol/Substance Abuse, other Other needs not identified on this assessment SERVICE NEEDED YES NO Comments *Client needs to fill out BEFORE interview for Caseworker to identify the needs of the household. Information is voluntary and confidential. Client Signature: 5

8 EOAC COMMUNITY PROGRAMMING RELEASE OF INFORMATION Client Name: I give permission to EOAC to share any information necessary with other individuals or organizations in order to provide case management services and secure resources on my behalf. I understand that information will only be shared when necessary to meet the requirements established by the program. I authorize EOAC to share my educational, services received information, and employment records with individuals and organizations as needed. Signed: Date: 6 Revised

9 CLIENT CONSENT AND RELEASE OF INFORMATION MAACLink is a computer system that is used locally as a Homeless Management Information System (HMIS). Use of an HMIS is required by the US Department of Housing and Urban Development (HUD) for agencies that receive HUD funding. MAACLink is not electronically connected to HUD and is only used by authorized agencies. All MAACLink users have received confidentiality training and have signed strict agreements to protect clients personal information and limit its use appropriately. A Privacy Notice is available at participating agencies. It provides details on how member agencies and their employees handle client information and data sharing. I give permission to (Agency Name) to collect and enter my personal and household information into the MAACLink computer system. I understand that the MAACLink system is shared with and used by authorized agencies in my community for the purposes of: 1. Assessing the needs of low-income, homeless or other special-needs people in order to give better assistance and to improve their current or future situations. 2. Improving the quality of care and service for people in need. 3. Tracking the effectiveness of community efforts to meet the needs of people who have received assistance. 4. Reporting data on an aggregate level that does not identify specific people or their personal information. I understand that: Information I give about my physical or mental health will NOT be shared outside the agency I am working with. I have the right to view my MAACLink file with an authorized user. Signing this release form does not guarantee that I will receive assistance. I may revoke my authorization by completing a revocation form. All agencies that use MAACLink will treat my information with respect and in a professional and confidential manner. Unauthorized people or organizations cannot gain access to my information without my consent. If I receive services from Homeless Prevention Rapid Re-Housing Federal Stimulus (HPRP) Funds, my information may be viewed by other participating agencies across Continuums of Care. Client Name (Printed) Client Signature Date Agency Representative Name (Printed) Agency Representative Signature Date

10 Client Name: Enter Dollar Amount Employment: Workers Compensation Social Security: Teachers Retirement: SSI: Housing Utility Assistance: SSDI: Insurance/Annuity: TANF/Food Stamps: Alimony: Retirement: Dividends/rental income: Veterans: Other: Student Financial Aid TOTAL INCOME: Pension: Unemployment: Self Employment Child Support: Enter Dollar Amount NECESSARY EXPENSES: TRANSPORTATION Food: Bus Fare: Rent/Mortgage: Car Payment: Electricity: Gasoline: Gas: Vehicle Insurance: Water: Repairs, License, etc. Child Care: OTHER EXPENSES Telephone: Church Donations: Savings: Cable TV/Internet: Trash: Cigarettes, Tobacco: Clothing, Diapers: Beverages, Snacks: Laundry, Dry Cleaning: Eating Out: Medical, Dental: Entertainment: Hair cuts: TOTAL EXPENSES Taxes: Insurance (Life, medical, rent): Other: EOAC Budget Counseling Worksheet INCOME-Last 30 Days-Including date of inteview EXPENSES-Last 30 Days TOTAL INCOME: TOTAL EXPENSES: TOTAL SPENDING MONEY: 8 Revised

11 Economic Opportunities Advancement Corporation Community Program 500 Franklin Ave Waco, TX (254) CLIENT EDUCATION MATERIAL I have received the Client Education printed material and a staff member of the EOAC Compressive Energy Assistance Program (CEAP) and/or Community Services Block Grant Program (CSBG) has explained to me the energy and money saving tips that this material contains. I understand that this form is for the Client Education items that I have received today. It does not make EOAC liable for any other services for my home. Yo Han recibido el material impreso y la educacion del cliente un miembro del personal de El EOAC compression Programa de Asistencia para Energia (CEAP) y/o Servicios a la Comunidad Block Grant Program (CSBG) me ha explicado la energia y consejos para ahorrar dinero que este material contiene. Yo entiendo que este formulario es para los elementos de clients de educacion que he recibido hoy. No tiene EOAC responsible de los otros servicios para me casa. O Energy Saver Booklet De ahorro de Energia Folleto O Calendar with energy saving tips Calendario con consejos para ahorrar energia O Other: Otros: Signed: Client Signature Firma de Cliente Date Fecha Signed: Case Worker Signature Firma de Trabajador de Casos Date Fecha 9 Revised

12 EOAC Texas Department of Housing and Community Affairs requires that ALL 18 years and older household members that do not have any income, complete the attached Declaration of Income statement and have the Statement of No Documented Proof of Income form notarized before eligibility can be determined on your case. Please ensure that this form is complete and notarized prior to your interview. Thank You, EOAC 10 Revised

13 DECLARATION OF INCOME STATEMENT (DECLARACION DE INGRESOS) I, do hereby declare on that: (Yo) (Applicant s Name/Nombre del Solicitante) (declaro que en esta fecha) (date) I have no documented proof of income due to the following: (No tengo documentación que compruebe mis ingresos por la siguiente razón:) I am applying for assistance with the agency: (Deseo aplicar para recibir asistencia de la agencia:) My household consists of persons and the following household members, 18 years and older that have earned the following gross income during the 30 day period prior to the date of this application for assistance. (En mi hogar viven personas. Los siguientes miembros de mi hogar tienen 18 años de edad o más y, durante los últimos 30 días antes de llenar esta aplicación, han recibido ingresos. (Indique el nombre y los ingresos de cada miembro) Name/ Nombre Name Nombre Name/ Nombre Name/ Nombre Name/ Nombre Gross Amount Ingresos Gross Amount Ingresos Gross Amount Ingresos Gross Amount Ingresos Gross Amount Ingresos My household s gross income, for all household members 18 years and older, for the 30 day period prior to the date of the application for assistance is ; (El total de los ingresos de mi hogar durante los últimos 30 días antes de la fecha de esta aplicación es de, y representa los ingresos para todos los miembros de mi hogar que tienen 18 años de edad o más.); and my household s gross annualized income based on the 30 day period prior to the date of this application is (El ingreso anual de mi hogar basado en los últimos 30 días antes de la fecha de mi aplicación es de ) I certify that the above information for the income of all household members 18 years and older is true and correct to the best of my knowledge and belief. (Certifico que la información de ingresos proveída de los miembros de mi hogar que tienen 18 años o más es verdadera y correcta según mi saber y entendimiento.) I understand that the information will be verified to the extent possible; and that I may be subject to prosecution for providing false or fraudulent information. (Comprendo que la información proveída en esta aplicación será verificada hasta donde sea posible y que puedo ser enjuiciado por haber proveído información falsa o fraudulenta.) Applicant Signature/Firma Date/Fecha Street Address/Dirección City/Ciudad County/Condado Zip/Código Postal Subrecipient Representative Date Reviewed by Signature and File Date

14 STATEMENT OF NO DOCUMENTED PROOF OF INCOME I,, do hereby declare on (Print name here) (Date) That I have no documented proof of income due to the following situation: I certify that the above information is true and correct. Client Signature Date This instrument was acknowledged before me this day of, 20 Notary Public, State of Texas 12

15 ECONOMIC OPPORTUNITIES ADVANCE CORPORATION OF PLANNING REGION XI Client's Statement of Self-Employment Income Declaracion de ingresos del negacio propio del cliente 1. Name of Person Having Self-Employment Income: Nombre de la persona que tiene ingresos de negocio propio: 2. Describe what you did to earn this money: Describa lo que hizo para ganarse este dinero: 3. List your business income, include any and all tips, for the last 30 day including today. Lista de ingresos de su negocio, incluyen consejos de todos y, para los últimos 30 días incluyendo hoy. DATE FECHA INCOME INGRESOS AMOUNT CANTIDAD TOTAL SELF-EMPLOYMENT INCOME TOTAL DE INGRESOS DEL NEGOCIO PROPIO The above information is true, correct, and complete to the best of my knowledge. I understand that giving false information could result in my being disqualified for fraud. Segun mi leal saber y entender, toda esta informacion es cierta, correcta y completa. Comprendo que se doy informacion falsa puedo ser discalificado por fraude. Signature/Firma Date/Fecha

16 EOAC APPLY FOR CHILD SUPPORT The Attorney General of Texas Apply Online: Once online you may apply for - Establishment of paternity - Establishment of child support, including if you already have an order OR Request an application - Online - By Phone, call REGISTER WITH WORK IN TEXAS (TEXAS WORKFORCE) Apply Online: OR By Phone: Monday - Friday from 8:00 a.m. to 5:00 p.m. CST Falls County Bosque/Hill County 230 Coleman 233 E. Elm Street Marlin, TX Hillsboro, TX Freestone/Limestone County McLennan County 517 Main 1416 South New Road Teague, TX Waco, TX

17 Assistance OTHER than EOAC you may qualify for: Assistance Paying Your Bill LITE-UP Texas Program The LITE-UP TEXAS program is designed to help qualified low-income individuals living in an area where they can choose their service provider, reduce the monthly cost of electric service. The program will provide discounts to eligible customers in the following months: May, June, July, and August 2015 bills An electric customer is qualified if the customer is currently receiving: Medicaid and SNAP. If you are not in one of the qualified programs listed above, you can still qualify in the program if your household income is at or below 125 percent of the federal poverty guidelines. If you are not a participant in the above qualified programs but think you qualify based on household income (see chart below) you can self-enroll by calling toll-free and request an application or by printing an application from this website. Number in Household Annual Income (125%) 1 14, , , , , , , ,113 Each additional add 5,200 IMPORTANT: The information on the electric bill (Name, Address, etc..) must match the information of the participant in the qualified program or the self-enrolled application. You can fax or your completed and signed scanned copy of your application, with all the backup information, to the administrator at: (toll free fax)