Fillable Application For Assistance

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Application For Assistance

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The Application For Assistance form is 5 pages long and contains:

  • 3 signatures
  • 48 check-boxes
  • 189 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Travis County Information Technology Services

BROWSE TRAVIS COUNTY INFORMATION TECHNOLOGY SERVICES (TX) FORMS

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Page 1
Pa
rt I – Applicant Information (please print)
Applicant’s Name: ______________________________________________________________________________________________________________________________________ __
Last First Middle Other Names Used/ Maiden Name
Physical Address: _______________________________________________________________________________________________________________________________________ __
Street Address &Unit Number City State Zip Code
Mailing Address: ______________________________________________________________________________________________________________________________________ ___
(
if different) Street/Box Number City State Zip Code
Phone Numbers: ( __________ ) ______________________ ( __________ ) ______________________ ( __________ ) ______________________ _________________________________________
Primary Phone Work or other Phone list Mobile Carrier/ Provider to receive text messages Email Address
Part II – Assistance Requested (Check each assistance type requested – in most cases more than one is selected.)
Rent/Mortgage
Electric
Heating Oil/Wood
Propane/Butane
Natural
Gas
Water
Trash
Food Pantry
Clothes
Weatherization
Home Repair
Social Worker Services
Information & Referral
Part III – Household Demographics
List ALL PERSONS living with you and answer each question for each person. (If additional space is needed, use a separate sheet of paper and attach to this document.) Indicate for each person separately
Name
(Include all persons living in the household)
to
Social Security
Number
Date of Birth
Age
Sex
M/F
His-
panic
Yes/No
Race
please
specify
U.S.
Citizen
Yes/No
Health
Insurance
Yes/No
Veteran
Yes/No
Receiving
Food
Stamps
Yes/No
Disabled
Yes/No
Last
Grade
in
School
1
.
2.
3.
4.
5.
6.
7.
8.
Application for Assistance
Travis County Health & Human Services
Family Support Services Division
OFFICE USE ONLY __________________________ Date Stamp
______ ____________________________________
___________________________________________
CABA #_____________________________________
Form CAA January 2019
YOU/YOURSELF
Self
Page 2
Expenses: Estimate the dollar amount your
household spends monthly – for payments and bills
Electric:
$
Food
$
Rent/Mortgage
$
Gas/Propane/Heat
$
Phone/Internet/Cable
$
Medical/ Health
Insurance Costs
$
Child Care
$
Credit Card Bills
$
Loans/Other
$
Income for your household (please include all payments received in past month)
Name of every
Household
Member with
Income or Benefits
How often is
Income Received?
(weekly, monthly,
every two weeks)
Source of Income (Social
Security, SSI, Pension,
Disability payments, Child
Support, Employer Name, etc.)
Total Gross
Dollars
Received in
past 30 days
You/ Yourself
1 What is your living situation? Own your home Rent your home Rent a Room Stay in Someone Else’s Home Stay in Shelter
Medical Facility/ Nursing Home
Sleep Outside or in a Car/vehicle
2 What type of home do you live in?
House Townhome/Apartment/Duplex Mobile Other/ Not applicable
3 Is your home Public Housing Authority Property Subsidized (an agency helps pay rent) Section 8 Voucher
4 Has your home been weatherized? (Weather stripping around the doors and windows, additional installation in the attic etc.)
YES
NO
5 What is the square footage of your home? ___________________ or UNKNOWN 6 How many bedrooms are in your home? __________
7 What is your home’s heating source?
Electric
Natural gas
Butane/Propane Heating oil Wood
8 What is your home’s cooling source?
Central air
Window unit
Other: _______________________ None
9 Are you worried or concerned that in the next two months you may not have
stable housing that you own, rent, or stay in as part of a household?
YES
NO
10 In the past 12 months, has the utility company shut off your service for not paying
your bills?
YES
NO
0
1
2
Never
Sometimes
Often
11
In the past 12 months, please indicate how often this describes you: I don’t
have enough money to pay my bills
12
In the last 12 months, please indicate how often this described you: The food that
we bought just didn’t last, and we didn’t have money to get more.
0
1
2
Never
Sometimes
Often
The information provided is true and correct to the best of my knowledge and belief. I understand this information may be checked with employers or other
sources. I am aware that I am subject to prosecution for providing false or fraudulent information. I understand I may request a hearing to appeal a denial of
eligibility, amount of assistance received, or a delay of service delivery.
Applicant or Representative Signature: ______________________________________________________ Date: ______________________
■
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Page 3
Family Support Services Division Agreement
• All of our services are voluntary; it is your choice to participate or not.
• Financial assistance is not guaranteed. No one is entitled to financial assistance.
• We will tell you about any financial assistance we can provide. If we cannot assist you, we will explain why and offer referrals to other options.
• We are committed to providing professional services to each individual according to the service needed and requested. Staff may not participate in
social gatherings, accept gifts or discuss your services or situation outside our professional relationship.
• This institution is an equal opportunity provider. We serve clients without discrimination based on age, creed, color, disability, gender, marital status,
national origin, race, religion, sex, or sexual orientation.
• We want to treat every client with respect and dignity; if at any time you feel we have not done this, please tell us. If you have a concern or
complaint, please let your worker know. You may also call the Center Administrator, Division Director, or County Executive at (512) 854-4100.
• We have several funding sources for utility assistance, not all require you to disclose or be a U.S. Citizen or qualified non-citizen.
Comprehensive Energy Assistance Program (CEAP) Information
One of our major funding sources for heating and cooling utilities is CEAP. We accept applications for CEAP at all Travis County Health and Human
Services Department Community Centers. No one is discouraged from applying for CEAP. To qualify for CEAP an applicant must be a Travis County
resident; meet income and other eligibility criteria; and be a U.S. Citizen or meet immigration status guidelines. Assistance is provided based on
eligibility, procedures, and availability of funds.
Are you a Citizen or Naturalized Alien?
YES
NO If no, are you a Qualified Alien
YES
NO
Your Responsibility as an Applicant for the Comprehensive Energy Assistance Program:
• Please continue making payments to your utility vendor. You are responsible for your bill and all utility costs. CEAP does not pay other parts of
your bill, such as water costs, trash, street lights, or any non- heating and cooling costs. Payments may not be for all of the bill or everything owed.
• You are subject to state and federal laws regarding fraud, and promise the information you provide is true and accurate. Anyone making intentional
or negligent statements is guilty of a felony that could result in fine, imprisonment, or both. Reference: Title 18, Section 1001 of the U.S. Code
• You have 20 days to appeal any decision after receiving written notice of that decision.
• Your signature on this page gives us permission to receive and share information with: Texas Department of State Health Services (DSHS); Texas
Department of Housing & Community Affairs (TDHCA); CEAP Sub-recipients; Social Security Administration (SSA); U.S. Citizenship and
Immigration Services—Systematic Alien Verification for Entitlements Program(SAVE).
My signature certifies I understand and have been explained my rights and responsibilities as a client of Travis County HHS Family
Support Services.
__________________________________________________ _________________
Signature of Client or Representative Date
__________________________________________________ _________________
Signature of Worker Verifying Client Understanding Date
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signature
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Page 4
Agreement and Release Concerning the Use of Client Information
You have requested services (Assistance) from Travis County ("County"). Your eligibility to obtain such Assistance from County is conditioned upon your
acceptance of the terms and conditions contained or referenced in this Authorization to Release Confidential Information (the "Authorization"). Please read this
Authorization carefully. By accepting the terms of this Authorization, you are authorizing County to share information about you that County obtained in order
to provide you with Assistance, as deemed necessary by County. The information about you that County may share may include your current and former
name(s), street address, and any other information County may have in its possession that County Obtained in order to provide you with Assistance (Client
Information). This may include Client Information you consider confidential or private. Any sharing or release of such Client Information will be made in
accordance with applicable law, rules and regulations. We may need to share Client Information about you to determine your eligibility, and to provide or obtain
Assistance.
Your signature on this page gives us permission to receive and share Client Information with County departments, funders of programs such as Family Eldercare,
County researchers and their sub-contractors. County reserves the right to modify, in part or in whole, or temporarily or permanently discontinue Assistance for
any reason and at any time without notice.
Your information will be kept private and within County, except as discussed on this page. We will not release Client Information about you unless:
• We believe your life or someone else’s life is in danger; or
• We believe a child, elderly person, or a person who is disabled is being abused or neglected or is in danger of being abused or neglected, including
financial abuse; or
• Your Client Information or records are ordered by a court of law to be released; or
• You give us written consent for your records or Client Information to be released to a third party
RELEASE AND INDEMNITY: You agree to release, indemnify, defend and hold County, its agents, employees, officers, directors and affiliates, harmless from
all liabilities, claims and expenses, including attorney's fees, from claims relating to or arising under requested services or this Authorization, including without
limitation, the disclosure of your Client Information. This release and indemnification will survive the termination of this Authorization.
ACCEPTED AND AGREED: This Authorization, unless revoked sooner expires one year from the date of my signature. My signature certifies that I
understand this Authorization and agree to the terms and the information I provided is true and correct to the best of my knowledge. I am aware that I
am subject to prosecution for providing false or fraudulent information.
__________________________________________________ _________________
Signature of Client or Representative Date
__________________________________________________ _________________
Signature of Worker Verifying Client Understanding Date
Please provide information for each of the following vendors to give County permission to discuss your financial assistance and share information with these vendors:
Name of Company (
City of Austin, PEC,
Bluebonnet, TXU, Tx Gas, etc.
):
Your Account Number
Customer Name on Bill
Electric
Gas/Propane
Water
Landlord or Mortgage Co Name:
Landlord Telephone Contact:
Landlord Email/Fax Contact:
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signature
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Page 5
Case Management Requests
Social Workers, Case Managers, and Caseworkers help clients in many different ways at the 7 Travis County Community Centers.
• Caseworkers focus on financial assistance such as rent and utility assistance
• Case Managers provide short term supportive case management (6 to 12 months), supporting you and your family to meet your goals to help
resolve short term issues or connect with other resources in the community.
• Social Workers are licensed mental health clinicians available to work with you over time in comprehensive case management (12 to 24
months). Working with the Social Worker, you may receive counseling services, help identifying goals, and work on complex, longer term needs.
☐ No case management or social work services requested just financial assistance (stop here)
Check any of the areas you would like to discuss with a Case Manager or Social Worker:
☐
Income: employment, training, information about applying for disability, social security, veterans benefits, money management/budgeting
☐
Basic Needs: food, clothing, hygiene, applying for food stamps, transportation
☐
Housing: homeless, temporary or transitional housing, threat of eviction, unaffordable housing
☐
Education: obtaining GED, ESL as a second language, literacy, enrolling self or children in school
☐
Health: medical needs, prescriptions, mobility, no insurance, applying for MAP, Medicaid, Medicare, or CHIP
☐
Mental Health: counseling, support groups, grief counseling, mental health medication, trauma symptoms, depression, anxiety
☐
Legal: outstanding tickets, warrants, probation, parole, legal services, divorce, child support, other legal needs
☐
Safety: domestic violence, child protective services, substance abuse, order of protection, feeling unsafe, safety planning
☐
Support: community involvement, lack of friend and family support, services for children, services for seniors
☐
Other:
If you have requested case management or social work services, we will be in contact with you. Please make sure we have as many ways to
reach you as possible, as if we cannot reach you, you may have to re-apply. We appreciate your patience!
Client Name: ____________________________ Phone Number_______________________
Message Number: ________________________ Email or Message Phone Number: ______________________________________
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Application For Assistance

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Completed 25 January 2020

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