Fillable ANCE - APPLICATION TB BANK COVID-19 RENTAL ASSIST

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ANCE - APPLICATION TB BANK COVID-19 RENTAL ASSIST

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TB BANK COVID-19 RENTAL ASSIST
ANCE - APPLICATION
This application must be complete and signed by all adult household members. Do not leave any blank lines, if information is
not applicable, write “N/A”. Any missing items will delay your application processing. Submission of an application does not
guarantee services.
Completed applications can be e-mail to PWhite@hepempowers.org, or delivered to 1120 N. Betty Lane, Clearwater FL 33755,
Monday – Friday, 8:30am – 5:00pm. Contact Phillip White at 727-442-9041 x 167 or Juliet Sanders x 168 for further questions.
S
ECTION
1
-
Q
UALIFYING
E
VENT
:
P
LEASE
E
XPLAIN HOW
COVID
AFFECTED YOUR INCOM
E AND HAS THREATENED
YOUR HOUSING STABILITY:
S
ECTION 2 - HOUSEHOLD INFORMATION:
H
EAD OF HOUSEHOLD INFORMATION:
What Months’ Rent are Being Requested?
Name:
Social Security #:
Date of Birth:
Gender:
Female
Male
Current Address:
City:
Zip Code:
Telephone Number:
Alternate Phone Number:
Email:
Marital Status:
Married Divorced Single
Are you a U.S. Citizen?
Yes No Are you a Veteran? Yes No
Are you moving to a new location with this assistance:
Yes No
Current Landlord Name:
Landlord Phone #:
Landlord Email or Fax:
O
THER ADULT HOUSEHOLD INFORMATION: (ANYONE OVER AGE 18 MUST COMPLETE THIS SECTION)
Name:
Social Security #:
Date of Birth:
Gender:
Female
Male
Current Address:
City:
Zip Code:
Telephone Number:
Alternate Phone Number:
Email:
Marital Status:
Married Divorced Single
Are you a U.S. Citizen?
Yes
No
Are you a Veteran? Yes No
O
THER HOUSEHOLD MEMBERS:
NAME(S)
R
ELATIONSHIP TO
APPLICANT
SOCIAL SECURITY # DATE OF BIRTH
S
ECTION 3 - EMPLOYMENT INFORMATION: (WRITE “NA” IF NOT APPLICABLE):
Employer:
Supervisor:
Position:
Phone:
Address:
Length of Employment:
Pay Rate:
Pay Frequency:
Other Adult HH Member:
Employer:
Position:
Supervisor:
Address:
Phone:
Length of Employment:
Pay Rate:
Pay Frequency:
(I
NCLUDE
P
UBLIC
B
ENEFITS
(F
OOD
S
TAMPS
),
SSI,
S
OCIAL
S
ECURITY
,
C
HILD
S
UPPORT
,
R
ETIREMENT
,
U
NEMPLOYMENT
,
VETERAN
BENEFITS, ETC.)
HOUSEHOLD MEMBER NAME TYPE OF INCOME AMOUNT
S
ECTION 4 - ASSET INFORMATION (FOR ALL HOUSEHOLD MEMBERS):
HOUSEHOLD MEMBER NAME NAME OF BANK
TYPE OF ACCOUNT
(SAVINGS, CHECKING, CD, ETC.)
CURRENT BALANCE
SECTION 5 - SUSTAINABILITY PLAN:
Please check one or more of the following to illustrate how you plan to maintain housing after the assistance has ended?
SECTION 8 OR OTHER RENTAL ASSISTANCE PROGRAMS
STEADY INCOME FROM EMPLOYMENT
ANTICIPATING ADDITIONAL FUTURE INCOME FROM SOURCE
(i.e. Child Support, Pension, Social Security, Disability, Insurances Claim, Workers Compensation Claim, etc.)
Other (please explain):
S
ECTION 6 - DEMOGRAPHIC INFORMATION: (FOR REPORTING PURPOSES ONLY, PLEASE CHECK ALL THAT APPLY)
E
THNICITY/RACE/SPECIAL NEEDS:
E
THNICITY
(M
UST
C
HECK
O
NE
)
R
ACE
(M
UST
C
HECK
O
NE
)
C
HECK
I
F
A
PPLICABLE
C
HECK
I
F
A
PPLICABLE
LIST ALL HOUSEHOLD
MEMBER NAME(S):
H
ISPANIC
OR
LATINO
N
ON
-
H
ISPANIC
OR NON-
L
ATINO
WHITE
B
LACK OR
AFRICAN
AMERICAN
N
ATIVE
HAWAIIAN
/ PACIFIC
I
SLANDER
ASIAN
AMERICAN
INDIAN OR
ALASKA
N
ATIVE
DISABLED VETERAN
S
ECTION 7 - CERTIFICATION:
I/we understand that Florida Statute 817 provides that willful false statements or misrepresentation concerning
income; asset or liability information relating to financial condition is a misdemeanor of the first
degree, punishable
by fines and imprisonment provided under Statutes 775.082 or 775.083. I/we further understand that any willful
misstatement of information will be grounds for disqualification. I/we certify that the application information
provided is t
rue and complete to the best of my/our knowledge. I/we consent to the disclosure of information for the
purpose of income verification related to making a determination of my/our eligibility for program assistance. I/we
agree to provide any documentation
needed to assist in determining eligibility and are aware that all information
and documents provided are a matter of public record.
Please be advised, HEP
collects your Social Security number for the following purposes: classification of
accounts; iden
tification and verification; credit worthiness; billing and payments; data collection,
reconciliation, tracking, benefit processing, tax reporting and qualification for grant or loan processing
under Section 119.071(5), Florida Statutes (2007). Social Se
curity numbers serve as a unique numeric
identifier and may be used for such purposes.
THIS DOCUMENT MUST BE SIGNED BY ALL ADULT HOUSEHOLD MEMBERS
APPLICANT SIGNATURE:
DATE:
ADULT HH MEMBER SIGNATURE:
DATE:
ADULT HH MEMBER SIGNATURE:
DATE:
HEP, Inc. | 1120 North Betty Lane, Clearwater, FL 34685 | 727.442.9041 | www.HEPempowers.org
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ANCE - APPLICATION TB BANK COVID-19 RENTAL ASSIST

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Completed 7 March 2022

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