Fillable CHAP Rental Assistance Required Documentation In order to

Fill Online, Printable, Fillable, Blank CHAP Rental Assistance Required Documentation In order to Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

CHAP Rental Assistance Required Documentation In order to

On average this form takes 38 minutes to complete

The CHAP Rental Assistance Required Documentation In order to form is 18 pages long and contains:

  • 6 signatures
  • 47 check-boxes
  • 106 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
CHAP Rental Assistance Required Documentation
CFDA 21.019
In order to complete a determination of eligibility, the required documents must be
provided. Please note that any applications that are submitted incomplete will not be
reviewed. A counselor will contact you within 72 hrs. from the time of submission by
email advising on items that are needed in order to identify eligibility.
__ Complete(d) signed CHAP Application
__ NHSSN Signed Disclosures
__HMIS Release
__COVID-19 Impact Statement
__COVID-19 Self Declaration-Liquid Assets (if applicable)
__ Photo Identification, regardless of state origin
__ Social Security Card or other proof of Social Security Number
__ Letter of explanation for those living in house with no income over the age of 18
__ Executed (all pages) Lease Agreement showing all occupants
__ Most recent utility bill in applicant’s name
Documentation to support COVID-19 financial impact. Documentation may include
but is not limited to:
__ 2019 W-2
__ SS/Death/Disability/Pension Benefit Statement
__ Proof of alimony/child support
__ Paystub prior to COVID-19 (March 1, 2020) and current paystubs to
demonstrate loss in income and most recent paystub, if applicable
__ Proof of Unemployment Insurance Benefits (UIB) or PUA, furlough letter,
termination letter, etc.
__ All household bank statements from March to current (all pages even if blank)
CHAP Rental Assistance Required Documentation
CFDA 21.019
__ 2019 filed income tax return – signed or if not filed, provide extension and 2018
signed returns
__ Other documents that indicate a loss/reduction in income related to COVID-19
For self-employed or business owners:
__ Copies of bank statements beginning February 2020
__ Most recent unaudited interim financial statement for 2020 and completed Profit
and Loss Statement Form
Required from your landlord:
__ Landlord Verification Form
__ W-9 Form
CFDA 21.019 CARES Housing Assistance Program Page 1
CARES Housing Assistance Program (CHAP)
Client Application for Rental Assistance
NHSSN Staff: _________________
Date Received: ________________
Status: ______________________
Outcome: ____________________
Last Name, First Name, Middle:
Date of Birth:
Age:
Current Address:
Telephone Number:
Email Address:
City, State, Zip:
Ethnicity:
US Citizen:
Primary Language:
Disabling Condition:
If yes, what type:___________________________
Specify Racial Group:
How did you hear about us:
Marital Status:
Housing Status:
Veteran:
Branch: _____ Year Entered:__________
Year Separated:
Discharge Status:
_
Theater: WWII
Theater: Korean War
Theater: Vietnam War
Theater: Persian Gulf War
Theater: Afghanistan
Theater: Iraq (Iraqi Freedom)
Theater: Iraq (New Dawn)
Theater: Other Operations ____________
__________________________________
Prior Living or Housing Situation (over 30 days):
Other: _______________________________________
How were you impacted by COVID-19 (check all that apply):
Loss of employment
Reduction in work hours
Furlough from employment
Reduction in income/salary due to reduced business revenue
Other (please specify): ____________________________________
________________________________________________________
Employment Status:
Monthly Income:
Total Monthly Amount:
Non-Hispanic
Yes
No
Stably Housed
Please Select
Please Select
Please select
Please select
Still in school
Please select
CFDA 21.019 CARES Housing Assistance Program Page 2
HOUSEHOLD SIZE: # of Adults # of Children (under 18)
PLEASE LIST ALL HOUSEHOLD MEMBERS
Name Relationship D.O.B Age
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
PARENTAL STATUS
FINANCIAL RESOURCES
$__________________________________________ $____________________________________________
Gross annual individual income Gross annual household income
Have you received cash income from any source listed below in the last 30 days?
Enter Income Sources and Amounts [Last 30 Days]
$ Earnings [Job or Commission] $ Veteran’s Pension
$ Unemployment Insurance [UI] $ Pension from Employment
$ Worker’s Compensation $ Temporary Assistance to Needy Families
$ Private Disability Insurance $ General Public Assistance
$ Veteran’s Disability Payments $ Alimony or Spousal Support
$ Social Security Disability Insurance [SSDI] $ Child Support
$ Supplemental Social Security [SSI] $ Social Security Retirement
$ Other Cash Income (tax return, Economic Impact Payment, _)
$___________________________________ Total Monthly Individual Cash Income Zero Income
Have you received non-cash benefits from any source listed below in the last 30 days?
Non-Cash Benefits Received [Last 30 Days]
Food Stamps or Benefit Card Medicaid (Health Insurance)
WIC (Supplemental Nutrition for Women, Infants, and Children) Medicare (Health Insurance)
Section 8 Public Housing or Rental Assistance TANF Child Care Services
Veteran’s Administration (VA) Medical Services TANF Transportation Services
SCHIP (State Children’s Health Insurance Program) Other TANF Funded Services
Other Non-Cash Benefits____________________________________
Please select
Please select
Please select
CFDA 21.019 CARES Housing Assistance Program Page 3
Does anyone of the above have income?
Who Source Amount
______________________________________ __________________________ _______________
______________________________________ __________________________ _______________
______________________________________ __________________________ _______________
Did you file your 2019 tax return?
Did you file your 2018 tax return?
Did you receive your Economic Impact Payment (Stimulus Check)?
PLEASE TELL US ABOUT YOUR EMPLOYMENT STATUS AND OTHER SOURCES OF INCOME/ASSETS
Current Employment Status:
If laid-off, date: _______________________________
Are you receiving Unemployment Insurance Benefits?
If yes, amount per week: _____________________
If denied benefits, did you file an appeal?
Date appeal filed: ________________________
Employer Name: _______________________________________________________________________
Employer Address: _____________________________________________________________________
Employer Phone Number: ________________________________________________________________
Position: ______________________________________________________________________________
Hourly Rate: ___________________________________________________________________________
If you are unemployed and have no income: How have you been paying your household/living expenses?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
How much assistance ($ amount) do you need?
Please select
Please select
Please select
Please select
Please select
Please select
CDFA 21.019 CARES Housing Assistance Program Page 4
Have you been served with an eviction notice?
Do you have a Lease, Rental Agreement or other legal contract for the housing you are
residing in?
Explanation:_____________________________________________________________________
Are you currently being assisted with Section 8, Public Housing, or a Tax-Credit Unit?
Are utilities included in your rent?
Have you paid any portion of the current month’s rent?
If yes, how much did you pay? $
Do you owe any late fees?
How much? $_
Have you paid the rent or any portion of the rent for last month?
How Much $
What was the last month you paid your rent in full?
How much do you have right now to pay towards your rent or utilities? $__________________
PLEASE TELL US ABOUT ANY PREVIOUS ASSISTANCE YOU HAVE RECEIVED FROM ANY OTHER
ORGANIZATION(S).
Financial Assistance with RENT in past 12 months: $
From ____________________
What other assistance have you applied for and where else have you tried to get help?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
What was the outcome?
___________________________________________________________________________________________
Please select one
Please select
Please select
Please select
Please select
Please select
Please select
CDFA 21.019 CARES Housing Assistance Program Page 5
I hereby certify, under penalty of fraud and perjury that all information provided on this application is
true and correct. I also certify that the all income resources and assets available to my household are
listed in their entirety on this application. I fully understand that any information or documentation
provided that is untrue can be used to deny my household the services for which I am applying and
may also be used in civil or criminal prosecution. Falsification or omission of any information on this
application, any program paperwork or any other documents may cause denial and/or termination of
any program services offered.
_____________________________ ___________________________________ _________________
Applicant Name Applicant Signature Date
CFDA 21.019
CARES Housing Assistance Program Information Release
I authorize the CHAP program staff to contact my landlord/property
manager, employer, agencies and individuals for information about my family or myself for the
purpose of rental assistance, case management and referrals. This authorization includes all
agencies and individuals with those I have worked or may work through referral by any agency.
This authorization will be considered a mutual release.
The release of content includes but is not limited to information regarding rental history, rental
amount, landlord information, income, employment, or other information needed to determine
eligibility and process request for rental assistance.
Applicant Printed Name
Applicant Signature Date
Signature Agency Staff Date
click to sign
signature
click to edit
click to sign
signature
click to edit
CFDA 21.019
Nevada Community Management Information System (CMIS) Client Consent for Data Collection and Release of Information
What is the CMIS?
The CMIS is a data system that stores information about homelessness services. Bitfocus, Inc. manages the CMIS for the CoCs within the
state of Nevada. The purpose of the CMIS is to improve services that support people who are homeless or at risk of homelessness to get
housing, and to have better access to those services, while meeting requirements of funders such as the U.S. Department of Housing and
Urban Development (HUD).
What is the purpose of this form?
With this form, you can give permission to have information about you collected and shared with Partner Agencies that help Nevada
provide housing and services. A current list of Partner Agencies is available at http://nvcmis.bitfocus.com/.
BY SIGNING THIS FORM, I AUTHORIZE the state of Nevada and Bitfocus to share CMIS information with Partner Agencies. The CMIS
information shared will be used to help me get housing and services. It will also be used to help evaluate the quality of housing and
service programs. I understand that the Partner Agencies may change over time.
The information to be collected and shared includes:
• Name, date of birth, gender, race, ethnicity, social security number, phone number, address
• Basic medical, mental health, substance use, and daily living information
• Housing Information
• Use of crisis services, veteran services, hospitals and jail
• Employment, income, insurance and benefits information
• Services provided by Partner Agencies
• Results from assessments
• My photograph or other likeness (if included)
BY SIGNING THIS FORM, I UNDERSTAND THAT:
• Bitfocus and Partner Agencies will keep my CMIS information private using strict privacy policies. I have the right to review their
privacy policies.
• I can receive a copy of this Consent and the Client Information Sheet
• I may refuse to sign this Consent. If I refuse, I will not lose any benefits or services.
• This Consent will expire 5 years from my last CMIS recorded activity.
I may revoke this Consent earlier at any time by returning a completed Revocation of Consent form, available at
http://nvcmis.bitfocus.com/, to nevada@bitfocus.com.
• The revocation will take effect upon receipt, except to the extent others have already acted under this Consent.
• My CMIS information may be viewed by auditors or funders who review work of the Partner Agencies, including
HUD, The Department of Veteran Affairs, and The Department of Health and Human Services. I understand that the
list of auditors and funders may change over time.
• My CMIS information may be shared to coordinate referral and placement for housing and services.
• My CMIS information may be further shared by the Partner Agencies to other agencies for care coordination,
counseling, food, utility assistance, and other services.
• My CMIS information will be used to help evaluate the quality of social services.
• My CMIS information may be used for research; however, my identity will remain private.
Signature of Client Date
PRINTED NAME
Refusing Consent and De-Identification of Information
If you refuse consent to have your information shared with Partner Agencies, the following information will be entered into the
system for your profile and will be deemed as anonymous or “de-identified”.
1. Your Social Security Number will be entered as all 0s and the Social Security Number Data Quality field will be set to Client
Refused;
2. Your Date of Birth will be entered as 01/01/[year of birth] and the Date of Birth Data Quality field will be set to Approximate or
Partial DOB Reported;
3. Your First Name will be entered as Anonymous;
4. Your Last Name will be entered as the Unique Identifier automatically assigned by Clarity Human Services; and
5. The Name Data Quality field will be set to Client Refused.
click to sign
signature
click to edit
CFDA 21.019
FOR AGENCY USE ONLY:
_____Client Opted Out (Refused Consent) ___________________________________________ _______________________
Staff Signature Date
____________________________________________________________________________________________________________________
Client Full Name, Social Security Number and/or Birthdate
CFDA 21.019
SELF DECLARATION OF LIQUID ASSETS
Name: _______________________________________ Last 4 SSN or Birthdate: _____________
All the boxes below must be checked, and all questions answered. This form must be completed in
order to process your application.
I do NOT have a checking/savings account
I do NOT have a prepaid card (ex. Netspend, Chime, GOBANK, Walmart Money Card, etc.)
The only liquid asset/savings I have is $__________________
Applicant must read the following and sign below:
I certify that all the information above is true and correct. I understand that this information is to be used
to determine eligibility for program assistance. I understand that the falsification or omission of any
information on my application, any program paperwork or any other documents may cause denial and/or
termination of any program services offered by CHAP and I may have to repay benefits received.
Signature of Applicant: ___________________________________ Date: _____________
Staff Signature: __________________________________________ Date: ______________
CARES Housing Assistance Program Unbanked Statement
Applicant Name: ____________________________________________________
Co-Applicant Name: _____________________________________________________
I (we) hereby certify that I (we) do not individually have a bank account currently.
Under penalty of perjury, I certify that the information presented above is true and accurate to
the best of my knowledge. I understand that providing false representations herein constitutes an
act of fraud and that providing misleading or incomplete information may result in denial of my
application.
_____________________________________________________________________________
Signature of Applicant
_____________________________________________________________________________
Signature of Co-Applicant (if applicable)
_______________________
Date
CDFA 21.019
Business Name:
Owner(s):
Signatures:
Date:
Profit and Loss for 2020 March April May June
Taxable Income:
Business Expenses:
Total Profit or Loss
CDFA 21.019
Self Employed Profit and Loss Statement
CARES Housing Assistance Program
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

CHAP Rental Assistance Required Documentation In order to

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 11 October 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document