Use block letters for text and mark appropriate boxes with an X. Complete a separate form for each household member.

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Use block letters for text and mark appropriate boxes with an X. Complete a separate form for each household member."

Transcription

1 Agency Name: CLARITY HMIS: HUD-COC INTAKE FORM Use block letters for text and mark appropriate boxes with an X. Complete a separate form for each household member. PROGRAM ENTRY DATE [All Clients] - - Month Day Year RELATIONSHIP TO HEAD OF HOUSEHOLD [All Clients] Husband Grandparent Father Grandchild Significant Other Mother Aunt Other Sister Uncle Wife Brother Niece Daughter Roommate Nephew Son SOCIAL SECURITY NUMBER [All Clients] - - QUALITY OF SOCIAL SECURITY Full SSN reported Approximate or partial SSN reported CURRENT NAME [All Clients] Last First Middle N/A Suffix QUALITY OF CURRENT NAME [All Clients] Full name reported Partial, street name, or code name reported DATE OF BIRTH [All Clients] - - Age: Month Day Year QUALITY OF DATE OF BIRTH Full DOB reported Approximate or partial DOB reported

2 GENDER [All Clients] Female Male Transgender male to female Transgender female to male If Other Specify: Other CONTACT INFORMATION [Optional] Phone Number - - Current Address (if applicable) Street City State Zip Code RACE [All Clients] American Indian or Alaskan Native Asian Black/African American Client Refused ETHNICITY [All Clients] n-hispanic n-latino Hispanic/Latino Hawaiian or Other Pacific Islander White/Caucasian Client does not know Data t Collected VETERAN STATUS [All Adults] IF YES TO VETERAN STATUS Year entered military service (year) Year separated from military service (year) Theater of Operations: World War II Theater of Operations: Korean War

3 Theater of Operations: Vietnam War Theater of Operations: Persian Gulf War (Desert Storm) Theater of Operations: Afghanistan (Operation Enduring Freedom) Theater of Operations: Iraq (Operation Iraqi Freedom) Theater of Operations: Iraq (Operation New Dawn) Theater of Operations: Other peace-keeping operations or military interventions (such as Lebanon, Panama, Somalia, Bosnia, Kosovo) Branch of the Military Army Coast Guard Air Force Navy Marines Discharge Status Honorable Dishonorable General under honorable conditions Uncharacterized Other than honorable conditions (OTH) Bad Conduct HOUSING STATUS AT ENTRY [Head of Households and Adults] Homeless Fleeing domestic violence At imminent risk of losing housing At-risk of homelessness Homeless only under other federal statutes Stably housed

4 RESIDENCE PRIOR TO PROGRAM ENTRY [Head of Households and Adults] Emergency shelter, including hotel or motel paid for Rental by client, with DPD TIP subsidy w/ emergency shelter voucher Foster care home or group home Rental by client, with other ongoing Housing subsidy Hospital or other residential non- Rental by client, with VASH subsidy psychiatric medical facility Hotel or motel paid for without emergency Shelter voucher Residential project or halfway house With no homeless criteria Jail, prison or juvenile detention facility Safe Haven Long-term care facility or nursing home Staying or living in a family member s Room, apartment or house Owned by client, no on-going housing subsidy Staying or living in a friend s room, apartment or house Owned by client, with ongoing housing subsidy Substance abuse treatment facility or detox center Permanent housing for formerly homeless persons (ex. CoC project, HUD legacy) Transitional housing for homeless persons (including homeless youth) Place not meant for habitation Other Psychiatric hospital or other psychiatric facility Rental by client, no ongoing housing subsidy Specify Other LENGTH OF STAY IN PREVIOUS PLACE One day or less One to three months Two days to one week More than three months, More than one week, but less than one month One year or longer LENGTH OF TIME ON STREET, EMERGENCY SHELTER, OR SAFE HAVEN [Head of Households and Adults] CONTINUOUSLY HOMELESS FOR AT LEAST ONE YEAR TIMES HOMLESS IN PAST THREE YEARS 0 4 or more NUMBER OF MONTHS HOMELESS IN PAST THREE YEARS 0-12 months (specify number of months): If more than 12 months, number of years: Length of time homeless documented?

5 IN PERMANENT HOUSING [RRH PROGRAMS ONLY - All Adults] Date of Move-In: / / DISABLING CONDITION [All Adults] PHYSICAL DISABILITY [All Clients] IF YES TO PHYSICAL DISABILITY SPECIFY Receiving services for physical disability Long-term physical disability Documentation of the disability and severity on file DEVELOPMENTAL DISABILITY [All Clients] IF YES TO DEVELOPMENTAL DISABILITY SPECIFY Currently receiving services for developmental disability Long-term developmental disability Documentation of the disability and severity on file CHRONIC HEALTH CONDITION [All Clients] IF YES TO CHRONIC HEALTH CONDITION SPECIFY Currently receiving services/treatment for this condition Long-term chronic health condition Documentation of the disability and severity on file

6 HIV-AIDS [All Clients] IF YES TO HIV-AIDS SPECIFY Currently receiving services/treatment for this condition Expected to substantially impair independence Documentation of the disability and severity on file MENTAL HEALTH PROBLEMS [All Clients] IF YES TO MENTAL HEALTH PROBLEMS SPECIFY Currently receiving services/treatment for this condition Long-term mental health problems Documentation of the disability and severity on file SUBSTANCE ABUSE PROBLEMS [All Clients] Both alcohol and drug abuse Alcohol abuse Drug abuse IF ALCOHOL ABUSE DRUG ABUSE OR BOTH ALCOHOL AND DRUG ABUSE SPECIFY Currently receiving services/treatment for this condition Long-term substance abuse problem Documentation of the disability and severity on file

7 DOMESTIC VIOLENCE [Head of Households and Adults] IF YES TO DOMESTIC VIOLENCE LAST OCCURANE Within the past three months Three to six months ago (excluding six months exactly) Six months to one year ago (excluding one year exactly) One year ago or more INCOME FROM ANY SOURCE [Head of Households and Adults] IF YES TO INCOME FROM ANY SOURCE INDICATE ALL SOURCES THAT APPLY Income Source Amount Income Source Amount Earned Income Unemployment Insurance Supplemental Security Income (SSI) Social Security Disability Income (SSDI) VA service-connected disability comp. VA non-service connected Disability pension Private disability insurance Worker s compensation Total monthly amount: TANF (Temporary Assistance to Needy Families) General Assistance (GA) Retirement income from Social Security Pension or retirement income from former job Child support Alimony and other spousal support Other source Specify Other RECEIVING NON-CASH BENEFITS [Head of Households and Adults] IF YES TO NON-CASH BENEFITS INDICATE ALL SOURCES THAT APPLY Special Supp. Nutrition Program for Women, infants and Children (SNAP) Other TANF Benefit WIC Section 8 TANF Childcare Other Source TANF Transportation Temporary Rental Assistance Specify Other

8 COVERED BY HEALTH INSURANCE [All Clients] IF YES TO HEALTH INSURANCE - HEALTH INSURANCE COVERAGE DETAILS MEDICAID Employer Provided MEDICARE Obtained through COBRA SCHIP Private Pay Health Insurance VA Medical State Health Insurance for Adults CURRENTLY ENROLLED IN SCHOOL [All Clients] NAME OF SCHOOL [If Applicable] IF YES TO CURRENTLY ENROLLED IN SCHOOL IS PROGRAM VOCATIONAL TRAINING OR APPRENTICESHIP HIGHEST LEVEL OF EDUCATION COMPLETED [All Clients] Schooling Grade 10 GED Nursery to Grade 4 Grade 11 Grades 5-6 Grade 12, Diploma Grades 7-8 High School Diploma Grade 9 Post Secondary School Signature of applicant stating all information is true and correct Date

HMIS Annual Assessment Form

HMIS Annual Assessment Form Name/Identification and Contact Information: Legal First Name: Legal Last Name: Program Name: Case Manager: HMIS consent form signed? Middle Name: Suffix: Program Entry Date: / / Date of Assessment: /

More information

Vendor Relations and Changing Software, 2010 HMIS-HEARTH Conference

Vendor Relations and Changing Software, 2010 HMIS-HEARTH Conference Vendor Relations and Changing Software, 2010 HMIS-HEARTH Conference Worksheet for HMIS Software Capacity Evaluation Introduction This tool is designed to help CoC and HMIS staff assess if a HMIS meets

More information

Homeless Count and Characteristics Survey Results. West Texas Homeless Network. January 22, 2015

Homeless Count and Characteristics Survey Results. West Texas Homeless Network. January 22, 2015 Number of surveys recorded 129 Number of adults in households 155 Number of children in households 45 Total number of people 200 1. Age Age Median 42.0 2. Gender Male 47 43.5 Female 61 56.5 Transgender

More information

Public Health Management Corporation. Address: Street City Zip Code. Medical Case Manager /Housing Counselor. Email:

Public Health Management Corporation. Address: Street City Zip Code. Medical Case Manager /Housing Counselor. Email: APPLICATION COVER PAGE Agency: Address: Street City Zip Code Medical Case Manager /Housing Counselor Phone: (Print Name) Email: I attest the information and documentation submitted is accurate and verified

More information

Homeless Count and Characteristics Survey Results. South Plains Homeless Consortium. January 22, 2015

Homeless Count and Characteristics Survey Results. South Plains Homeless Consortium. January 22, 2015 Number of surveys recorded 263 Number of adults in households 278 Number of children in households 73 Total number of people 351 1. Age Age Median 41.0 2. Gender Male 123 58.3 Female 88 41.7 Transgender

More information

9. WILL THE INFORMATION I GIVE BE CHECKED? Yes and we may also ask you to send written proof.

9. WILL THE INFORMATION I GIVE BE CHECKED? Yes and we may also ask you to send written proof. Dear Parent/Guardian: Children need healthy meals to learn. Your child s school offers healthy meals every school day. Your childr en may qualify for free meals or for reduced price meals. 1. DO I NEED

More information

CAMDEN COUNTY. PITC Homeless

CAMDEN COUNTY. PITC Homeless CAMDEN COUNTY On January 25, 2012 there were 662 homeless men, women and children counted in Camden County according to the U.S. Department of Housing and Urban Development (HUD) regulations. 900 PITC

More information

Application for Vocational Rehabilitation Services

Application for Vocational Rehabilitation Services Strong Families Make a Strong Kansas Application for Vocational Rehabilitation Services Is Vocational Rehabilitation the right program for you? Some brief information about the Vocational Rehabilitation

More information

CASE MANAGEMENT INVENTORY OF SUPPORT SERVICES For Adults

CASE MANAGEMENT INVENTORY OF SUPPORT SERVICES For Adults COMMONWEALTH OF PENNSYLVANIA BUREAU OF DRUG and ALCOHOL PROGRAMS Division of Treatment CASE MANAGEMENT INVENTORY OF SUPPORT SERVICES For Adults NAME : SSN: ADDRESS PHONE: (Street) ISS Interval Scores CIS

More information

24. How does your disability keep you from working, or cause problems in your ability to maintain work? phone: phone: phone: date(s) date(s) date(s)

24. How does your disability keep you from working, or cause problems in your ability to maintain work? phone: phone: phone: date(s) date(s) date(s) USOR-4 (Rev. 8/04) Utah State Office of Rehabilitation VOCATIONAL REHABILITATION APPLICATION PART I: Tell us about yourself. 1. Social Security Number (Office use only) Case #: 2. Legal Name (Last) (First)

More information

Homeless Operations Management and Evaluation System (HOMES) Homeless Services Assessment Form

Homeless Operations Management and Evaluation System (HOMES) Homeless Services Assessment Form Assessment Form (rev. 1/13/12) page 1 of 11 Homeless Operations Management and Evaluation System (HOMES) Homeless Services Assessment Form Shaded items show elements that are collected elsewhere in HOMES

More information

ASPIRA Management Information System OJJDP General Intake Information

ASPIRA Management Information System OJJDP General Intake Information ASPIRA Management Information System OJJDP General Intake Information Name: First Name Middle Name Last Name Nick Name Birth Date: (month/day/year) Address: Street Name Apt. # City State Zip Code Supplemental

More information

Dear Community Kitchen Academy Applicant:

Dear Community Kitchen Academy Applicant: Dear Community Kitchen Academy Applicant: Thank you for your interest in the Community Kitchen Academy Training Program. Our training is 13 weeks long and will meet daily 9:00 A.M. to 3:00 P.M., Monday

More information

Application. For Veterans Care Health Insurance. Veterans Care covers veterans who need health insurance. Other Important Information

Application. For Veterans Care Health Insurance. Veterans Care covers veterans who need health insurance. Other Important Information Application For Veterans Care Health Insurance There are thousands of veterans in Illinois who are living without health insurance because they can t afford it. The citizens of Illinois feel a sense of

More information

RENTAL APPLICATION Caldwell Housing Authority 22730 Farmway Road Caldwell, Idaho 83607 (208) 459-2232

RENTAL APPLICATION Caldwell Housing Authority 22730 Farmway Road Caldwell, Idaho 83607 (208) 459-2232 SECTION 1: APPLICANT INFORMATION RENTAL APPLICATION Accessible unit needed: Yes No (mm/dd/yyyy): Applicant Name (first, middle initial, last): Applicant (SSN): Sex: Male Female of Birth (mm/dd/yyyy): Age:

More information

SAMPLE SUPPORTIVE HOUSING INTAKE/ASSESSMENT FORM

SAMPLE SUPPORTIVE HOUSING INTAKE/ASSESSMENT FORM SAMPLE SUPPORTIVE HOUSING INTAKE/ASSESSMENT FORM (This form must be completed within 30 days of program entry) IDENTIFYING INFORMATION Date Information is Gathered: 1. Applicant Last Name: First Name:

More information

Start Making the Most of Your Money!

Start Making the Most of Your Money! Start Making the Most of Your Money! Answer 23 simple questions and you will get a personal report with tips on money management and budgeting, staying healthy, and protecting your financial information.

More information

St. Louis County Project Homeless Connect. Summary of guests served on October 24, 2007

St. Louis County Project Homeless Connect. Summary of guests served on October 24, 2007 St. Louis County Project Homeless Connect Summary of guests served on October 24, 2007 J A N U A R Y 2 0 0 8 St. Louis County Project Homeless Connect Summary of guests served on October 24, 2007 January

More information

Homeless Management Information System (HMIS) Indiana Housing & Community Development Authority

Homeless Management Information System (HMIS) Indiana Housing & Community Development Authority Homeless Management Information System (HMIS) Indiana Housing & Community Development Authority 3.2.2012 Homeless Management Information System (HMIS) New User Training A Homeless Management Information

More information

NATIONAL YOUTH IN TRANSITION DATABASE SURVEY QUESTIONS

NATIONAL YOUTH IN TRANSITION DATABASE SURVEY QUESTIONS 1. Currently are you employed full-time? NOTE: Full-time means working at least 35 hours per week at one or multiple jobs 2. Currently are you employed part-time? NOTE: Part-Time means working at least

More information

2016 Homeless Count Results Los Angeles County and LA Continuum of Care. Published by: Los Angeles Homeless Services Authority May 4, 2016 1

2016 Homeless Count Results Los Angeles County and LA Continuum of Care. Published by: Los Angeles Homeless Services Authority May 4, 2016 1 2016 Homeless Count Results Los Angeles County and LA Continuum of Care Published by: Los Angeles Homeless Services Authority May 4, 2016 1 Why Do We Count? The Homeless Count seeks to answer key questions

More information

VETERANS INNOVATIONS PROGRAM APPLICATION

VETERANS INNOVATIONS PROGRAM APPLICATION VETERANS INNOVATIONS PROGRAM APPLICATION COUNTY: APPLICATION DATE: PROGRAM: Defenders Fund Individual Grant PERSONAL INFORMATION Full Name (last, first, middle) Social Security Number Phone Number Message

More information

HMIS Data Standards Manual

HMIS Data Standards Manual HMIS Data Standards Manual A Guide for HMIS Users, CoCs and System Administrators Released August, 2014 U.S. Department of Housing and Urban Development Version 2.1 Contents About this Manual... 6 Key

More information

Health Coverage & Help Paying Costs Application for One Person

Health Coverage & Help Paying Costs Application for One Person THINGS TO KNOW Health Coverage & Help Paying Costs Application for One Person Use this application to see what insurance choices you qualify for Free or low-cost insurance from Medicaid or the Kentucky

More information

L E T T E R T O H O U S E H O L D

L E T T E R T O H O U S E H O L D Free and Reduced Price School Meals Letter to Households Page 1 of 1 L E T T E R T O H O U S E H O L D Dear Parent/Guardian: School Year 2014 2015 * * * * * * * * * * * * * * * NEW THIS SCHOOL YEAR!!!

More information

ECEC Application Revised 01.5.15

ECEC Application Revised 01.5.15 Salt River Pima-Maricopa Indian Community Early Childhood Education Programs Mailing Address: 10, 005 E. Osborn Road Physical Address: 4815 N. Center Street Scottsdale, AZ 85256 Phone: 480-362-2200 Fax:

More information

Massachusetts HIV Drug Assistance Program (HDAP) and Comprehensive Health Insurance Initiative (CHII) Application Form

Massachusetts HIV Drug Assistance Program (HDAP) and Comprehensive Health Insurance Initiative (CHII) Application Form Massachusetts HIV Drug Assistance Program (HDAP) and Comprehensive Health Insurance Initiative (CHII) Application Form Please print clearly and answer all questions. Review the attached instructions before

More information

ADMISSION PACKET IMPORTANT SUBMISSION INSTRUCTIONS

ADMISSION PACKET IMPORTANT SUBMISSION INSTRUCTIONS ADMISSION PACKET IMPORTANT SUBMISSION INSTRUCTIONS This OREGON VETERANS HOME ADMISSION PACKET contains the forms required by the Oregon Department of Veterans Affairs (ODVA) to apply for residency at one

More information

C A L H O U N COUNTY SCHOO LS

C A L H O U N COUNTY SCHOO LS C A L H O U N COUNTY SCHOO LS Dear Parent/Guardian: Children need healthy meals to learn. Calhoun County Schools offers healthy meals every school day. Breakfast costs $1.50; lunch costs $1.75. Your children

More information

Trumbull Career and Technical Center 528 Educational Highway Warren, Ohio 44483 Toll Free 1-866-737-6925

Trumbull Career and Technical Center 528 Educational Highway Warren, Ohio 44483 Toll Free 1-866-737-6925 Trumbull Career and Technical Center 528 Educational Highway Warren, Ohio 44483 Toll Free 1-866-737-6925 Dear Parent/Guardian: Children need healthy meals to learn. TCTC offers healthy meals every school

More information

HOW TO APPLY FOR FREE AND REDUCED PRICE SCHOOL MEALS

HOW TO APPLY FOR FREE AND REDUCED PRICE SCHOOL MEALS HOW TO APPLY FOR FREE AND REDUCED PRICE SCHOOL MEALS Please use these instructions to help you fill out the application for free or reduced price school meals. You only need to submit one application per

More information

Counts! Bergen County s 2016 Point-In-Time Count of the Homeless. January 26, 2016

Counts! Bergen County s 2016 Point-In-Time Count of the Homeless. January 26, 2016 NJ 6 Counts! Bergen County s 6 Point-In-Time Count of the Homeless January 6, 6 Table of Contents I. Introduction... NJ Counts 6... Acknowledgements... This Report... II. Data Collection and Methodology...

More information

Lee County Central Point of Coordination Application Return Application Requested By: HIPPA Yes NO. Date of Application: / / Phone: #( )- -

Lee County Central Point of Coordination Application Return Application Requested By: HIPPA Yes NO. Date of Application: / / Phone: #( )- - Lee County Central Point of Coordination Application Return Application Requested By:_ HIPPA Yes NO Date of Application: / /Phone: #()-- Name of Applicant: Last First M.I. Current Address: City State Zip

More information

CROSSROADS ENROLLMENT APPLICATION (Please carefully read and print all answers. All blank spaces must be filled.)

CROSSROADS ENROLLMENT APPLICATION (Please carefully read and print all answers. All blank spaces must be filled.) P a g e 1 CROSSROADS ENROLLMENT APPLICATION (Please carefully read and print all answers. All blank spaces must be filled.) Personal Information Today s Date: Name: First: M.I.: Last: Preferred Name: Maiden

More information

Low-Income Telephone and Electric Discount Programs (LITE-UP) Enrollment Form

Low-Income Telephone and Electric Discount Programs (LITE-UP) Enrollment Form Low-Income Telephone and Electric Discount Programs (LITE-UP) Enrollment Form The LITE-UP Texas Program can: 1. Provide a discount off your monthly telephone bill. 2. Provide a discount on your electric

More information

Application for Free Home Repairs

Application for Free Home Repairs Application for Free Home Repairs Name of Homeowner: Date of Birth: Gender Male Female Is this a female headed household? Is this a grandparent headed household? Street Address: City: County: Zip Marital

More information

ServicePoint Supportive Service Workflow for CoC SSO Projects

ServicePoint Supportive Service Workflow for CoC SSO Projects ServicePoint Supportive Service Workflow for CoC SSO Projects 8/27/2015 10/20/2015 Update 1 Overview Supportive Service projects (SSOs) are an important piece of the process of ending homelessness in our

More information

MA Free and Reduced Price School Meal Application

MA Free and Reduced Price School Meal Application Student Name: School: Grade: FREQUENTLY ASKED QUESTIONS ABOUT FREE AND REDUCED PRICE SCHOOL MEALS Dear Parent/Guardian: Children need healthy meals to learn. [Lenox Public Schools] offers healthy meals

More information

HARTLAND CONSOLIDATED SCHOOLS

HARTLAND CONSOLIDATED SCHOOLS HARTLAND CONSOLIDATED SCHOOLS Lisa Archey, Student Nutrition Director 10632 Hibner Rd. Telephone (810) 626 2867 Hartland, MI 48353 Fax (810) 626 2869 FREQUENTLY ASKED QUESTIONS ABOUT FREE AND REDUCED PRICE

More information

Application for Health Coverage & Help Paying Costs

Application for Health Coverage & Help Paying Costs Application for Health Coverage & Help Paying Costs Form Approved OMB No. 0938-1191 Use this application to see what coverage choices you qualify for Who can use this application? Affordable private health

More information

Veterans Home Ownership Program Application

Veterans Home Ownership Program Application Veterans Home Ownership Program Application Thank you for your interest in the Veteran Home Ownership Program. Completing this application does not guarantee you a home. Completing this application will

More information

Application for Employment Related Day Care (ERDC) Program

Application for Employment Related Day Care (ERDC) Program Application for Employment Related Day Care (ERDC) Program Please read these instructions before filling out this application. Answer all questions. Do not write in the shaded areas. To contact our office

More information

VA DATA GUIDE - FY2015

VA DATA GUIDE - FY2015 VA DATA GUIDE - FY2015 Data Collection and Reporting Guidance for SSVF Grantees PREPARED FOR Department of Veterans Affairs Technology Acquisition Center 260 Industrial Way West Eatontown, New Jersey 07724

More information

LIFELINE AND LINK-UP ASSISTANCE APPLICATION

LIFELINE AND LINK-UP ASSISTANCE APPLICATION LIFELINE AND LINK-UP ASSISTANCE APPLICATION Whether you re a first-time applicant or missed your recertification deadline, you must complete and submit a new application form. The easiest way to apply

More information

A String Theory School

A String Theory School A String Theory School www.stringtheoryschools.com West Campus Vine Street Campus East Campus 2600 South Broad Street 1600 Vine Street 2407 South Broad Street Philadelphia, PA 19145 Philadelphia, PA 19102

More information

Apply for Free and Reduced Price Meals OR Prepay for Meals Online!

Apply for Free and Reduced Price Meals OR Prepay for Meals Online! Stafford County Public Schools Apply for Free and Reduced Price Meals OR Prepay for Meals Online! Dear Parent/Guardian, Stafford County Public Schools Is pleased to announce the availability of applying

More information

Evaluation at the Recovery Centers Last Updated July 10, 2013

Evaluation at the Recovery Centers Last Updated July 10, 2013 Evaluation at the Recovery Centers Last Updated July 10, 2013 How do you identify: 1. I consider myself (please check all that apply): a person with a history of alcohol or drug abuse/addiction a person

More information

2015-2016 Independent Verification

2015-2016 Independent Verification V6- IND FORM 2015-2016 Independent Verification Your 2015-2016 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called Aggregate Verification. Northern is required

More information

A Quick Summary for Domestic Violence Advocates

A Quick Summary for Domestic Violence Advocates A Quick Summary for Domestic Violence Advocates of the March 2010 HMIS Final Regulations The final regulations for HMIS were released in March 2010 and these regulations are generally a positive step in

More information

INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR PARTICIPATION IN THE ADDP AND/OR HICP PROGRAM

INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR PARTICIPATION IN THE ADDP AND/OR HICP PROGRAM New Jersey Department of Health AIDS Drug Distribution Program (ADDP) and Health Insurance Continuation Program (HICP) PO Box 722 Trenton, NJ 08625-0722 INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR

More information

Apply faster online at Compass.ga.gov.

Apply faster online at Compass.ga.gov. GEORGIA DEPARTMENT OF HUMAN SERVICES Division of Family and Children Services Application for Health Coverage & Help Paying Costs Form Approved OMB No. 0938-1191 Use this application to see what coverage

More information

MILFORD EXEMPTED VILLAGE SCHOOL DISTRICT Nutrition Services 777 Garfield Avenue Milford, OH 45150 (513) 831-5030

MILFORD EXEMPTED VILLAGE SCHOOL DISTRICT Nutrition Services 777 Garfield Avenue Milford, OH 45150 (513) 831-5030 MILFORD EXEMPTED VILLAGE SCHOOL DISTRICT Nutrition Services 777 Garfield Avenue Milford, OH 45150 (513) 831-5030 **NOW AVAILABLE** ONLINE FREE AND REDUCED APPLICATIONS FOR MILFORD EXEMPTED VILLAGE SCHOOLS

More information

Massachusetts Application for Health and Dental Coverage and Help Paying Costs

Massachusetts Application for Health and Dental Coverage and Help Paying Costs Massachusetts Application for Health and Dental Coverage and Help Paying Costs THINGS TO KNOW HOW TO APPLY Use this application to see what coverage choices you may qualify for. Who can use this application?

More information

Instructions for Completing a Medicare Savings Program (MSP) Application

Instructions for Completing a Medicare Savings Program (MSP) Application Instructions for Completing a Medicare Savings Program (MSP) Application The attached Department of Human Services (DHS) Health Services Application is used to apply for Medicare Savings Programs (MSP)

More information

Application for Health Coverage & Help Paying Costs

Application for Health Coverage & Help Paying Costs Application for Health Coverage & Help Paying Costs Use this application to see what coverage choices you qualify for Who can use this application? Affordable private health insurance plans that offer

More information

State Guidelines Point in Time and Housing Inventory Count of Homeless Persons. January 2016

State Guidelines Point in Time and Housing Inventory Count of Homeless Persons. January 2016 State Guidelines Point in Time and Housing Inventory Count of Homeless Persons January 2016 Contact Information For more information concerning these Guidelines, and the Homelessness Housing and Assistance

More information

Application for Admission

Application for Admission Admissions Office 800 U.S. Highway 29 N. Athens, GA 30601-1500 706-355-5004 Fax 706-369-5756 Elbert County Campus 1317 Athens Highway Elberton, GA 30635 706-213-2100 Fax 706-213-2149 Greene County Campus

More information

Your Texas Benefits: Getting Started

Your Texas Benefits: Getting Started Your Texas Benefits: Getting Started SNAP Food Benefits (This used to be called Food Stamps.) Helps buy food for good health. Some people might get help the next work day. TANF Cash Help for Families TANF:

More information

Health Insurance for Illinois Families. Rod R. Blagojevich, Governor

Health Insurance for Illinois Families. Rod R. Blagojevich, Governor Health Insurance for Illinois Families Rod R. Blagojevich, Governor KC 2378KC (R-3-04) IL478-2437 KidCare and FamilyCare Plans KidCare and FamilyCare are health insurance plans for Illinois residents.

More information

Easy Does It, Inc. Transitional Housing Application

Easy Does It, Inc. Transitional Housing Application Easy Does It Inc. of Reading and Leesport Housing Programs Easy Does It, Inc. Transitional Housing Application Welcome Thank you for applying to Easy Does It, Inc. ( EDI ) a non-profit charitable organization

More information

2015-2016 Dependent Verification

2015-2016 Dependent Verification V6- DEP FORM 2015-2016 Dependent Verification Your 2015-2016 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called verification. Northern must compare information

More information

NOTICE OF DIRECT CERTIFICATION

NOTICE OF DIRECT CERTIFICATION East Catholic School 2001 Ardmore Blvd. Pittsburgh, PA 15221 Phone: 412/351-5403 Fax: 412/273-9114 www.eastcatholicschool.org Dear Parent/Guardian: Children need healthy meals to learn. East Catholic School

More information

ACCESS NY HEALTH CARE Child Health Plus / Family Health Plus / Medicaid / PCAP / WIC

ACCESS NY HEALTH CARE Child Health Plus / Family Health Plus / Medicaid / PCAP / WIC ACCESS NY HEALTH CARE Child Health Plus / Family Health Plus / Medicaid / PCAP / WIC PLEASE READ the entire application and INSTRUCTIONS before you fill it out. Print clearly in blue or black ink. If you

More information

MANIILAQ ASSOCIATION EMPLOYMENT & TRAINING

MANIILAQ ASSOCIATION EMPLOYMENT & TRAINING Direct Employment (DE) Funds: Provides assistance with pre-employment needs such as work-clothes, tools, utilities, deposit and first month's rent, groceries, and basic household needs not to exceed $4000.

More information

Florida s Families and Children Below the Federal Poverty Level

Florida s Families and Children Below the Federal Poverty Level Florida s Families and Children Below the Federal Poverty Level Florida Senate Committee on Children, Families, and Elder Affairs Presented by: February 17, 2016 The Florida Legislature Office of Economic

More information

Application for Health Coverage & Help Paying Costs

Application for Health Coverage & Help Paying Costs Application for Health Coverage & Help Paying Costs Use this application to see what coverage choices you qualify for Who can use this application? Affordable private health insurance plans that offer

More information

Y O U T H L E A D. Summer U LEAD Program Application

Y O U T H L E A D. Summer U LEAD Program Application Summer U LEAD Program Application Y O U T H L E A D U LEAD is sponsoring a summer job program for Ramsey County Suburban youth ages 14 to 24. Youth must complete the summer application and complete work

More information

Introduction to Veteran Treatment Court

Introduction to Veteran Treatment Court Justice for Vets Veterans Treatment Court Planning Initiative Introduction to Veteran Treatment Court Developed by: Justice for Vets Justice for Vets, 10 February 2015 The following presentation may not

More information

STATE OF TENNESSEE EMPLOYMENT APPLICATION

STATE OF TENNESSEE EMPLOYMENT APPLICATION USE BLACK INK ONLY TO COMPLETE THIS APPLICATION FORM. REQUIRED FIELDS OR YOUR APPLICATION WILL BE RETURNED TO YOU. PLEASE COMPLETE ALL Please record your Social Security Number below. List the specific

More information

Homeless Operations Management and Evaluation System (HOMES) User Manual Phase 1

Homeless Operations Management and Evaluation System (HOMES) User Manual Phase 1 Homeless Operations Management and Evaluation System (HOMES) User Manual Phase 1 Submitted by Jones Lang LaSalle April 19, 2011 FINAL DRAFT Table of Contents I. INTRODUCTION...1 A. BACKGROUND...1 B. HOMES

More information

Yes. Concerns expressed by: Medical Provider Primary care provider Social Service Agency Family Member Program Staff Other (Please Indicate): _

Yes. Concerns expressed by: Medical Provider Primary care provider Social Service Agency Family Member Program Staff Other (Please Indicate): _ Page 1 ~ Martin County Community Action, Inc. Head Start Program P.O. Box 806/415 E. Blvd. Suite 130 Williamston, NC 27892 (252) 789-4930 Fax: (252) 792-1838 DPlease bring proof of income, child's birth

More information

Long-Term Homeless Definitions and Eligibility Questions

Long-Term Homeless Definitions and Eligibility Questions Long-Term Homeless Definitions and Eligibility Questions Definitions Homeless (Minnesota): A household lacking a fixed, adequate night time residence (includes doubled up). Households Experiencing Long-Term

More information

Report of Veterans Arrested and Booked

Report of Veterans Arrested and Booked Report of Veterans Arrested and Booked into the Travis County Jail A Project of the Veterans Intervention Project Compiled by: Travis County Adult Probation Department Travis County Pretrial Services Travis

More information

PRISM SECTION 1 OVERVIEW. Number of times divorced. Number of times widowed

PRISM SECTION 1 OVERVIEW. Number of times divorced. Number of times widowed START TIME : PRISM SECTION 1 OVERVIEW Statement A.1: I would like to begin by asking you some questions about your background. 1. -----------------------------------------------> Sex 1 MALE 2 FEMALE 2.

More information

Family-Related Medical Assistance Application

Family-Related Medical Assistance Application Family-Related Medical Assistance Application Form Approved DCF. CF-ES 2370, Dec 2013 THINGS TO KNOW Use this application to see what coverage choices you qualify for Free or low-cost insurance from Medicaid

More information

MEDICAL ASSISTANCE (MA)/MCHP APPLICATION FOR FAMILIES, PREGNANT WOMEN, AND CHILDREN

MEDICAL ASSISTANCE (MA)/MCHP APPLICATION FOR FAMILIES, PREGNANT WOMEN, AND CHILDREN Si necesita ayuda para llenar el formulario favor de llamar al 1-800-456-8900 Please PRINT in blue or black ink. MEDICAL ASSISTANCE (MA)/MCHP APPLICATION FOR FAMILIES, PREGNANT WOMEN, AND CHILDREN Date

More information

CLIENT INTAKE REPORT. DEMOGRAPHIC TAB: Name: / / Gender: [ ] Male [ ] Female [ ] Transgender ([ ] Male to female [ ] Female to male) [ ] Unknown

CLIENT INTAKE REPORT. DEMOGRAPHIC TAB: Name: / / Gender: [ ] Male [ ] Female [ ] Transgender ([ ] Male to female [ ] Female to male) [ ] Unknown Part B URN # Client Part C # CLIENT INTAKE REPORT Date: DEMOGRAPHIC TAB: Name: / / (Last) (First) (MI) Preferred name you want to be called: Gender: [ ] Male [ ] Female [ ] Transgender ([ ] Male to female

More information

Application for Health Coverage & Help Paying Costs (Short Form)

Application for Health Coverage & Help Paying Costs (Short Form) Form Approved OMB No. 0938-1191 Application for Health Coverage & Help Paying Costs (Short Form) Use this application to see what coverage you qualify for Affordable private health insurance plans that

More information

You will need to mail or fax us copies of items that apply to your case. See the next page for a list of these items.

You will need to mail or fax us copies of items that apply to your case. See the next page for a list of these items. Getting started: Health care for children CHIP and Children s Medicaid These programs offer health-care benefits for newborns and children age 18 and younger who live in Texas. With these programs, your

More information

Data Quality Plan Louisiana Service Network Data Consortium

Data Quality Plan Louisiana Service Network Data Consortium Data Quality Plan Louisiana Service Network Data Consortium November 2nd, 2012 Developed by: LSNDC Data Quality Committee Data Quality 1.0 Definition: Data Quality Plan A data quality plan is a document

More information

2015 2016 Household Resources Verification Worksheet. V6-Dependent Student

2015 2016 Household Resources Verification Worksheet. V6-Dependent Student 2015 2016 Household Resources Verification Worksheet V6-Dependent Student Your 2015 2016 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called Verification. The Financial

More information

Resource Family Application Registration / Update Form (CY 131) Instructions

Resource Family Application Registration / Update Form (CY 131) Instructions Submit to When to use Used By Comments Resource Family Application Registration / Update Form (CY 131) Instructions Pennsylvania Adoption Exchange, P.O. Box 4469, Harrisburg PA 17111-0469, fax to 1-717-236-8510.

More information

AFCARS ASSESSMENT IMPROVEMENT PLAN: Foster Care Elements State: Florida

AFCARS ASSESSMENT IMPROVEMENT PLAN: Foster Care Elements State: Florida #8 Child Race #52 1 st Foster Caretaker s Race #54 2 nd Foster Caretaker s Race (if applicable) 2 Screen: Person Management; Basic Screen/Extraction Code Screen/Code Tab 1) Modify the program code to 1)

More information

Yurok Child Support Services 427 F Street, Ste. 236 P.O. Box 45 Eureka, CA 95502 Phone: (707) 269-0695 Fax: (707) 269-0645

Yurok Child Support Services 427 F Street, Ste. 236 P.O. Box 45 Eureka, CA 95502 Phone: (707) 269-0695 Fax: (707) 269-0645 Yurok Child Support Services 427 F Street, Ste. 236 P.O. Box 45 Eureka, CA 95502 Phone: (707) 269-0695 Fax: (707) 269-0645 APPLICATION FOR CHILD SUPPORT SERVICES OFFICE USE ONLY: Date Requested: Date received:

More information

Application for Health Coverage & Help Paying Costs

Application for Health Coverage & Help Paying Costs Application for Health Coverage & Help Paying Costs Use this application to see what coverage choices you qualify for Affordable private health insurance plans that offer comprehensive coverage to help

More information

2015 2016 Verification Worksheet Independent Student- Group 6

2015 2016 Verification Worksheet Independent Student- Group 6 Student Financial Services 1200 East Colton Avenue, Redlands, CA 92373-0999 Telephone: (909) 748-8047 Email: sfs@redlands.edu Fax: (909) 335-5399 Web site: www.redlands.edu/financialaid.asp 2015 2016 Verification

More information

BELLHINGHAM HILL FAMILY HOMES APPLICATION FOR HOUSING

BELLHINGHAM HILL FAMILY HOMES APPLICATION FOR HOUSING BELLHINGHAM HILL FAMILY HOMES APPLICATION FOR HOUSING 55 Library Street and 158-164 Shawmut Street, Chelsea, MA Opening Summer 2014 Thank you for your interest in Bellingham Hill Family Homes! Please read

More information

SCILC Statewide Needs Assessment

SCILC Statewide Needs Assessment SCILC Statewide Needs Assessment Thank you for taking the time to complete this survey. It is designed to measure barriers in the community for people with disabilities so that the SC Statewide Independent

More information

COUNTY OF POLK Community, Family & Youth Services. Application Guidelines

COUNTY OF POLK Community, Family & Youth Services. Application Guidelines Application Guidelines In order to be eligible for you must: Reside in Polk County Be over 18 or an emancipated minor Meet income and eligibility guidelines Apply first for any state or federal programs

More information

Family Shared Cost Program

Family Shared Cost Program Family Shared Cost Program Thank you for your interest in the CCHC Family Shared Cost Program. The FSCP is designed to provide quality, compassionate health care regardless of an individual s financial

More information

Please answer all questions which apply to you and mark those that do not apply with N/A. LAST NAME FIRST NAME MIDDLE NAME

Please answer all questions which apply to you and mark those that do not apply with N/A. LAST NAME FIRST NAME MIDDLE NAME CRIMINAL JUSTICE INSTITUTE University of Arkansas System 26 Corporate Hill Dr Little Rock, Arkansas 72205 (501) 570-8000 APPLICATION FOR EMPLOYMENT The Criminal Justice Institute is an Equal Opportunity/Affirmative

More information

How to Apply To complete your application, here s what you need to do:

How to Apply To complete your application, here s what you need to do: What is Kern Medical Center Health Plan (KMCHP)? KMCHP is a county and federally-funded program that provides medical care to some people living in Kern County. It s a new way for Kern residents who meet

More information

Health Benefits for Workers with Disabilities Application

Health Benefits for Workers with Disabilities Application Illinois Department of Public Aid Health Benefits for Workers with Disabilities Application Note: This is NOT an application for cash assistance, food stamps or enrollment in the Medicaid spenddown program.

More information

APPLY ON-LINE at. InsureAlabama.org. health coverage.

APPLY ON-LINE at. InsureAlabama.org. health coverage. APPLY ON-LINE at InsureAlabama.org Application for Health Coverage & Help Paying Costs Use this application to see what coverage choices you qualify for Affordable private health insurance plans that offer

More information

White Earth Early Learning Scholarship Program Information about the program Household Size Gross income How to complete the application:

White Earth Early Learning Scholarship Program Information about the program Household Size Gross income How to complete the application: White Earth Early Learning Scholarship Program White Earth Child Care/Early Childhood Programs Funded by MN s Race to the Top Early Learning Challenge Grant Information about the program Use this application

More information

Application for Health Coverage and Help Paying Costs

Application for Health Coverage and Help Paying Costs Iowa Department of Human Services Application for Health Coverage and Help Paying Costs Use this application to see what coverage choices you qualify for Affordable private health insurance plans that

More information

Monterey County Behavioral Health 2013 Satisfaction Survey Outcomes

Monterey County Behavioral Health 2013 Satisfaction Survey Outcomes SERVICE AREA - DUAL DIAGNOSIS TREATMENT DTH Co-occuring Disorder SD (BVCSOCSDV) DTH Santa Lucia (CDCSOC) Youth Surveys High Performing Indicators (75% and above) Low Performing Indicators (below 75%) Positive

More information

V6-Independent Student

V6-Independent Student 2015 2016 Household Resources Verification Worksheet V6-Independent Student Your 2015 2016 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called Verification. The

More information

Homelessness in Greater New Orleans: A Report on Progress toward Ending Homelessness May 2012

Homelessness in Greater New Orleans: A Report on Progress toward Ending Homelessness May 2012 Homelessness in Greater New Orleans: A Report on Progress toward Ending Homelessness May 2012 Introduction The 2012 Homeless Point in Time (PIT) Count for New Orleans and Jefferson Parish took place on

More information

Application for Health Coverage & Help Paying Costs

Application for Health Coverage & Help Paying Costs Application for Health Coverage & Help Paying Costs Use this application to see what coverage choices you qualify for Affordable private health insurance plans that offer comprehensive coverage to help

More information