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160 E Kellogg Blvd, St Paul, MN 55101 (Ramsey County)

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160 E Kellogg Blvd, St Paul, MN 55101
Ramsey County Emergency Assistance (EA) & Emergency General Assistance (EGA) Application
Name ______________________________________
Phone _______________________
What is Your Emergency? (check one)
Utility Crisis (threat of gas/electric
disconnect or water disconnect)
Program Open:
SNAP Y es N o
CASH Yes No
Xcel/Utility Account Number
_________________________
Is your power off now? Yes No
S
helter Crisis (eviction, past due rent, mortgage or damage deposit)
Landlord/Caretaker Name______________________________________
Landlord Phone Number_______________________________________
FOR STAFF USE ONLY
Application Date _____________
Denied Date________________
Approved Date _________________
Amount(s) __________ __________
Mandatory Vendor Required? Yes ___ No ___
If yes, Vendor Period ___________
Vendor N
umber and
Amount
______________ ____________
______________ ____________
Financial Worker Name
____________________________
Approve Vendor with HRF/CSR/ER ____
Update Addr/Shel ____
Other HH Changes (See below) ________
___________________________________
Additional Action for Financial Worker
Screened
RCHW 3614 FAS Revised: 07/2020
Case Number __________________
Healthcare Yes No
___________________________
SECTION 8 VOUCHER INFORMATION
County policy says Emergency Assistance can't
pay for a deposit if you have already moved in. If
you move in while your application is pending,
and we deny your EA, we won’t be able to
approve you on a new application.
If you have Section 8, EA can't pay for your
deposit until your home has passed inspection. EA
can't pay for any rent due from before the unit
passes inspection.
Emergency Car Repair
Ramsey County Emergency Assistance (EA) & Emergency General Assistance (EGA) Screening Sheet
Applicant’s Legal Name Birth Date Social Security Number
Street Address City County State Zipcode
Need interpreter? Yes ___ No ___
Ten Digit Home Phone Number Other Phone Number Language if you need interpreter
List all of the people living in your home, including roommates, even if you are not applying for them. You must give social
security numbers only for people who are applying for help
Full Legal Name Social Security Number Birth Date Relationship to You
1
2
3
4
5
6
7
8
9
RCHW 3614 FAS Revised: 07/2020
1. Which of the following is your emergency need?
Ev
iction
Damage Deposit
C
ar Repair
Utility Shut Off
2. Do you qualify for us to waive some requirements for eligibility?
If you are a family, or a pregnant woman and you are homeless, living in a contracted Ramsey County homeless shelter, or you are in a
transitional living, supportive housing program or a B
attered Women Shelter, we may be able to waive certain requirements for
determining eligibility.
Name of Shelter _______________________________________________________________
3.
Have you paid any shelter costs (such as rent, mortgage, hotel,or people you have stayed with) in the last 30 days?
Yes No If yes, Attach proof of payment - receipts or a statement from the landlord verifying dates and amount paid.
4. Have you paid any utilities (electric, gas and water only) in the last 30 days?
Yes No
If yes, Name of Company ____________________________________________ Account # ______________
5. Have you paid any daycare expenses in the last 30 days?
Yes No If yes, provide information below AND Attach proof of payment
Child’s Name Amount Paid by You Date Paid
RCHW 3614 FAS Revised: 07/2020
6. Has anyone in your household had a job in the last 30 days?
Yes No If yes, provide information below-Attach copies of all pay stubs received in last 30 days.
7. Did anyone in your household receive income from self-employment such as: product sales, personal services,
farming, paper route, in-home daycare, property rental, taxi driver, etc?
Yes No If yes, provide information below and Attach business ledgers - Verify dates and income received.
Household Member’s Name Type of Business Income Received in the last 30 days
8. Does anyone in your household receive any of the following sources of income?
If yes Attach proof – verify dates and type of income.
Income Type X if Yes Member with Income Amount in the last 30 days
Social Security (RSDI)
Supplemental Security Income (SSI)
Veteran Benefits
Unemployment Insurance
Retirement Benefits
Spousal/ Child Support
Public Assistance (such as MFIP/MSA / GA)
Income Tax Refund
Financial Aid/Loans
Other Income – Name it :
RCHW 3614 FAS Revised: 07/2020
9. Does your household have any of the Following Expenses?
Yes No If yes, provide information below. If yes Attach proof – verify amounts below
Expense Type
X if Yes
Expense Amount
Rent
Mortgage
Heating
Electric
Water/Sewer
10.
Do you live in subsidized housing?
Yes
No
If yes, attach proof
What is the total rent? $___________
What is your portion? $___________
11.
Does anyone in your household own any of the following assets?
Yes No
If yes, provide information-Attach Statement from last 30 days. If
you closed an account, Attach Proof of Closure from bank
RCHW 3614 FAS Revised: 07/2020
Asset Type
Member with Asset
Asset Amount
Bank Account
Retirement Account
Stocks/Bonds/Contracts for Deed
Oth
er Securities (Name them here)
A portion or all of my cash assistance grant may be sent directly to my landlord or utility company for a
period up to 24 months from the date of approval of emergency funds. If I am not willing to agree to
vendoring, I may not be eligible for emergency assistance funds.
By signing, I give my consent to Ramsey County Financial Services to release, share and obtain information about
me or my records for the purpose of verifying eligibility factors in the determination of Emergency Assistance/
Emergency General Assistance. For example, Ramsey County FAS may use this release to contact a lan dlord/
property owner, utility company, employer(s), financial and educational institutions, etc., as needed for the sole
purpose of determining eligibility.
I understand this information about me is protected under state and/or federal privacy laws and/or laws specifically
protecting medical and chemical abuse treatment records and cannot be disclosed without my written authorization
unless otherwise provided for by State or federal law. I hereby voluntarily and knowing ly waive those protections
and consent to the release of this information.
I understand I may submit a written request to revoke this at any time.
I understand that revoking this authorization does not apply to information already released under it.
I understand information disclosed to an individual or entity other than Ramsey County may be redisclosed to
other parties and may no longer be protected under privacy laws.
I understand one year from the signed date, this consent au tomatically expires without my express revocation.
I must agree to mandatory vendoring if determined appropriate by my worker.
READ YOUR RIGHTS & RESPONSIBILITIES BEFORE SIGNING
Authorization for the Release/Sharing/Obtaining of Information
I declare under penalties of perjury I have examined this application, and to the best of my knowledge it is a true and correct statement of
every material point.
________________________________________________________________
Signature
_________________________________________
Date
RCHW 3614 FAS Revised: 07/2020
RETAIN THIS PAGE FOR YOUR RECORDS
Your responsibilities
• You must report changes with may affect your benefits to the county agency within 10 days after the change
has occurred. Applicants - Report these changes to your worker when the change happens. This includes the
following for everyone in your household:
ₒ Employment – Start or stop of a job or business; change in ours, earnings or expenses
ₒ Income – Receipt or change in child support, Social Security, Veteran benefits, Unemployment
Insurance, inheritance, insurance benefits and other payments.
ₒ Property – Purchase, sale or transfer of house, car or other items of value. Get inheritance or settlement.
ₒ Household – When a person dies or becomes disabled, moves in or out of your home or temporarily
leaves; pregnancy; birth of a child.
ₒ Address
ₒ Housing costs/rent subsidy
ₒ Utility costs
ₒ Filing a lawsuit
ₒ Absent parent custody or visits
ₒ Drug felony conviction
ₒ Marriage, separation or divorce
ₒ School attendance
ₒ Health insurance coverage and premiums
Note for child care providers: If you change providers, you must tell your child care worker and provider at
least 15 days before the change goes into effect. If you have any questions or are unsure about any reporting
rules, contact your worker. If your worker is not available, leave a message so the worker can get back to you.
• The county, state or federal agency may check any of the information you give. To get some information we
must have your signed consent. If you don’t allow the county to confirm your information, you might not
get assistance.
• If you give us information you know is untrue or we get information you did not report, we will investigate
you for fraud.
• The State or Federal Quality Control agency may randomly choose your case for review. They will review
statements you made on forms. They will check to see if we figured your eligibility correctly. The state
agency may seek information from other sources. The State or Federal Quality Control agency will tell you
about any contact they intend to make. If you do not cooperate, your benefits may stop.
Cooperation Requirements:
RAMSEY COUNTY
Financial Assistance Services
• If the county approves you for the Minnesota Family Investment Program (MFIP) or the Diversionary Work
Program (DWP), you must cooperate with employment services, unless you are exempt. You must develop
and sign an employment plan or your DWP application will be denied.
• To receive Family Cash Benefits and/or Child Care Assistance (CCAP), you must cooperate with child
support enforcement for all children in the household. You have a right to claim “good cause” for not co-
operating with child support enforcement. You must assign child support to the State of Minnesota for all
eligible children. If you do not cooperate or assign your child support, benefits will be denied or terminated.
• After the county approves your MFIP or DWP, if you get child support directly from the noncustodial parent
you must report it to your worker. You must cooperate with the child support agency in any legal action
brought against a 3rd party for payment of medical expenses, unless you claim and are granted good cause.
• If you are applying for health care for yourself and your children and you do not live with the other parent,
you may have to give information about the other parent to child support staff. Child support staff may use
this information to pursue medical support for your children. You do not have to give this information if you
are applying for your children or are pregnant.
• Household members applying for health care may need to accept and keep other health insurance that is
available. This includes Medicare. If you do not give us information about your policy, you may not get
coverage.
RCHW 3614A FAS Revised: 07/2020
Your Rights
• Your right to privacy. Your private information, including your health information, is protected by state and
federal laws. Your worker has given you a Notice of Privacy Practices (DHS-3979) information sheet
explaining these rights.
• You have the right to reapply at any time if your benefits end
• You have the right to know why, if we have not processed your application promptly.
ₒ 15 days for medical care for pregnant women
ₒ 30 days for cash, SNAP and child care
ₒ 45 days for medical care
ₒ 60 days for cash and medical care related to disability
• You have the right to know the rules of the program you are applying for and for us to tell you how we
figured your benefits.
• You have the right to choose where and with whom you live and, within certain limits, to choose your own
doctor, hospital, etc.
• Appeal rights. If you are unhappy with the action taken or feel the agency did not act on your request for
assistance, you may appeal. For cash, child care and health care, you may appeal within 30 days from the
date you receive the notice by writing to the county agency, or directly to the State Appeals Office at the
Minnesota Department of Human Services, P.O. Box 64941 St. Paul, MN 55164-0941. (If you show good
cause for not appealing your cash and health care within 30 days, the agency can accept your appeal for up
to 90 days from the date you receive the notice.) For SNAP, you may appeal within 90 days by writing or
calling the county or the State Appeals Office. If you wish your assistance to continue until the hearing, you
must appeal before the date of the proposed action or within 10 days after the date the agency notice was
mailed, whichever is later. Ask your county worker to explain how the timing of your appeal could affect
your present or future assistance.
• Access to free legal services. Contact your worker for information on free legal services.
• Your right to file a complaint. If you feel the county or the Minnesota Department of Human Services
treated you differently in the handling of your public assistance application or benefits because of race,
color, national origin, political beliefs, religion, creed, sex, sexual orientation, public assistance status, age
or disability, including physical access to government buildings, you may file a complaint with your county
agency or any of the following agencies.
MN Dept of Human Services
Equal Opportunity and Access
P.O. Box 64997
St Paul, MN 55164-0997
651-431-3040 (Voice)
(866) 786-3945 (TTY)
MM Dept of Human Rights
Freeman Building
625 Robert Street North
St Paul, MN 55155
(800) 657-3704 (voice)
(651) 296-1283 (TTY)
U.S. Dept of Health &Human
Services
Office for Civil Rights, Region V
233 North Michigan Avenue, # 240
Chicago, IL 60601
(312) 886-2359 (Voice)
(312) 353-5693 (TTY)
In accordance with Federal and U.S. Department of Agriculture policy, this institution is prohibited from
discrimination on the basis of race, color, national origin, sex, age, religion, political beliefs, or disability. To
file a complaint of discrimination, write:
U.S. Department of Agriculture
Director, Office of Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410
(800) 795-3272 (Voice) / (202) 720-6382 (TTY)
USDA is an equal opportunity provider and employer.
RCHW 3614B FAS Revised: 07/2020
RAMSEY COUNTY
Financial Assistance Services
Verifications for
Emergency Assistance (EA)
Emergency General Assistance (EGA)
Below is a list of verifications you need to send in with your application for Emergency
Assistance/Emergency General Assistance. Your financial worker will let you know if you
need to provide further information.
Please send in the following verifications by:
Copy of any eviction notice
Copy of any utility di
sconnection notice XCEL Account #
Earned Income – past 30 days of paystubs for any household member
Current bank statement showing date and balance for any household member
Receipt or verification of rent/mortgage in past 30 days
Receipt or verification of utility paid in past 30 days
Copy of lease or shelter form if applying for Damage Deposit
Others: _________________________________________________________
Note:
Your worker cannot determine eligibility without the required verifications. You may fax
verifications to the emergency assistance line: 651-266-3909. Include your case number
on all faxes. The emergency Hotline phone number is 651-266-4884. It may take up to 5
business days for your worker to review your application.
Everyone applying for EA/EGA is subject to the same procedures and policies. An application
is not a guarantee of eligibility.
RCHW 3614C FAS Revised: 07/2020 (also p. 9 of 3614)
Case Number:
160 E Kellogg Blvd, St Paul, MN 55101
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160 E Kellogg Blvd, St Paul, MN 55101 (Ramsey County)

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Completed 23 November 2020

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