Fillable Community Action Partnership of San Bernardino County INTAKE

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Community Action Partnership of San Bernardino County INTAKE

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1/8/2020 10:11 AM
Community Action Partnership of San Bernardino County INTAKE ASSESSMENT FORM
Property Address:
Phone #:
Client ID #:
Housing Type: Apartment House Mobile Other *Applicant: Do Not Complete. This section is for official use only
Rent Own Homeless Other Permanent Housing Other Service(s) Requested: Utilities Weatherization Temporary Housing Food
Family Type: Single parent /female Single parent /male Secondary Education Workforce Development Permanent Housing
Two-parent household Single person 2 Adults- no children Other Public Transportation Gas Card California ID
*# of Disconnected Youth: Youth ages 14-24 who are neither working or in school Personal Hygiene / Household Items Clothing / Shoes (for work)
*Language: **Language:
English Spanish Other:
Other:
Email Address:
Use the KEY below to complete this section for occupants living in the home within the last 30 days (insert Numbers Only)
Household Members
Date of Birth
(xx/xx/xx)
Social Security Number
(xxx-xx-xxxx)
Gender
(Female,
Male, Other)
Disabled
(Yes, No)
Race
Ethnicity
Health
Insurance
Type
Highest
Level of
Education
Residency
Status
Relation
to
Applicant
Income
Source(s)
Non-
Cash
Benefits
Monthly
Income
Military
Status
Work
Status
( Applicant )
F
M
O
Y
N
$
F
M
O
Y
N
$
F
M
O
Y
N
$
F
M
O
Y
N
$
F
M
O
Y
N
$
F
M
O
Y
N
$
Race
1. White
2. African-American
3. Asian
4. Native American/
Alaskan Native
5. Hawaiian/Pacific
Islander
6. Multi-Race
7. Other
Ethnicity
1. Hispanic
2. Non-
Hispanic
Health Insurance
1. None
2. Medicaid
3. Medicare
4. Employment-based
5. Military
6. State Children’s
Health Insurance
Program
7. State health
Insurance for
adults
8. Direct Purchase
9. Other
Education
1. 0-8 grade
2. 9-12
th
grade
3. High School
Grad / GED
4. Some
College
5. 2-Year
College Grad
6. 4-year
College Grad
7. Other/ Post-
Secondary
Graduate
Residency
Status
1. U.S. Citizen
2. Permanent
-Resident
3. Temporary
-Resident
4. Other
Relation to
Applicant
1. Self
2. Spouse
3. Daughter
4. Son
5. Grandchild
6. Mother
7. Father
8. Sister
9. Brother
10. Foster Child
11. Other
*Income Source
1. None
2. Employment
3. TANF
4. SSI
5. SSDI
6. Retirement / Social
Security
7. VA Service
8. VA Non-Service
9. Private Disability Ins.
10. Workers Compensation
11. Pension
12. Child Support
13. Alimony/ Spousal
Support
14. EITC
15. Unemployment
16. Other
*Non-Cash Benefits
1. None
2. SNAP
3. WIC
4. *LIHEAP
5. Housing Choice
Voucher
6. Public Housing
7. Permanent
Supportive Housing
8. HUD-VASH
9. Childcare Voucher
10. Affordable Care
Act Subsidy
11. Other
Military
Status
1. None
2. Active
Military
3. Veteran
*Work Status
1. None
2. Employed full-time
3. Employed part-time
4. Farm Worker
5. Unemployed (less than
6 months)
6. Unemployed (more than
6 months)
7. Unemployed (not in labor
force/ not looking)
8. Retired
9. Not Applicable (less than
18 yrs. old)
By signing below, I agree that all the above information is accurate and complete.
Applicant’s Signature:
Date:
Intake Staff Printed Name:
CAP33 | Intake Assessment Form | Rev11/22/19mmclean
Put Notary stamp below, if needed (DOE only) or have
Executive Director Sign here
Department of Community Services and Development
CSD 43B (rev.12/2013)
CERTIFICATION OF INCOME AND EXPENSES
You are being asked to complete this form because you requested assistance, and state that your entire household cannot provide proof
of income. The State of California requires the applicant to report all sources of income. This form will help us understand how you are
meeting expenses. Please complete the information below:
Name and Address
Name:
Address:
Section 3: Please tell us how you paid these monthly expenses during the previous months:
EXPENSE
MONTHLY
COST
HOW HAS THE EXPENSE BEEN PAID?
IF SOMEONE ELSE PAYS FOR YOU, PLEASE COMPLETE:
Rent or
Mortgage
$
Name:
Phone:
Address:
Utility
Bills
$
Name:
Phone:
Address:
Food
$
Name:
Phone:
Address:
Section 4: If none of the above applies to you, please explain how your monthly expenses were paid:
Signature:
By signing this form, I affirm that I believe these facts are accurate and true. I give the Service Provider my permission to verify this information.
I may be held liable under federal or state law for knowingly making false or fraudulent statements.
Signature
Date
Section 1: Do you have sources of income you forgot to report?
YES
NO
During the previous month have you been employed part time?
YES
NO
During the previous month have you been self-employed?
YES
NO
During the previous month did you receive money for any work that you perform only once in a while, like yard work,
child care, donating blood, etc?
YES
NO
During the previous month have you received any gifts of money from anyone? If yes, please list the name and phone
number of the person who gave you the gift:
YES
NO
During the previous month did you receive any of the following: (circle any that apply)
WORKER’S COMP
UNEMPLOYMENT
GOVERNMENT SPONSORED BENEFITS
CHILD SUPPORT
YES
NO
Do you receive any of the following (circle any that apply)
ANNUITY PAYMENT
PENSION
TRIBAL CASINO PAYMENTS
RENTAL INCOME
INSURANCE BENEFITS
Section 2: Are you spending your savings or borrowing money to
cover monthly expenses?
YES
NO
Are you using savings or a home equity loan?
How much? ____________________________
YES
NO
Are you using some other asset?
How much?____________________________
YES
NO
Are you borrowing from credit cards?
How much?____________________________
YES
NO
Are you borrowing from some other source?
How much?____________________________
Page 1 of 1
Department of Community Services and Development
Account Holder Authorization and Consent Form
CSD Form 081 (Rev. 12/17)
ACCOUNT HOLDER NAME(S) AND MAILING ADDRESS
Account Holder’s Full Name
Account Holder’s mailing address (Street)
Unit Number (if any)
(City)
State
Zip Code
Is the utility service address the same as the account holder’s mailing address? Yes No
Full Name of Applicant for Benefits (from Form 43)
Utility Service Address (Street)
Unit Number (if any)
(City)
State
CA
Zip Code
UTILITY INFORMATION
Please enter your utility company name and service account number below (you can find the account number on your bill). If
different companies provide your electricity and gas services, please enter the name and account number for both utilities.
Name of Utility Company
Service Account Number
Name of Utility Company (if you have a second Utility Company)
Service Account Number
AUTHORIZATION AND CONSENT
By signing this form, you (Account Holder) give your authorization and consent (permission) to CSD, its contractors,
consultants, other federal or state agencies (CSD Partners) and to your utility company and its contractors, to share
information about your property’s utility account, meter usage and energy consumption data, and other information as needed
for the period beginning 24 months prior to, and continuing for 36 months after, the date signed below. The information you
authorize us to obtain and share will be used for the purposes of evaluating home energy usage of program beneficiaries so
that CSD can: a) measure the effectiveness of the services we provide by determining how much your utility bills are reduced
and how much our services reduce carbon emissions (air pollution), and b) report these results to federal and state authorities
that fund and oversee energy assistance programs in California. CSD, its contractors, consultants, other federal or state
agencies and affiliated programs (CSD Partners), working cooperatively with your utility company and its contractors, use this
information to provide services that assist low-income families, such the applicant, to pay their home energy bills and mange
those energy needs for the purposes stated in this Authorization.
REVOCATION OF AUTHORIZATION AND CONSENT
You agree that your consent shall remain in effect for 36 months from the date you sign this Authorization, unless otherwise
revoked by written notice mailed to: CSD Energy & Environmental Services Division, 2389 Gateway Oaks Drive, Suite 100,
Sacramento, CA 95833. Revocation will be effective upon receipt, but will not apply to any information shared while this
Authorization was valid.
APPLICABLE PROGRAMS
Some of the programs CSD oversees or partners with include:
- CSD Federal Low-Income Home Energy Assistance Program (LIHEAP)
- CSD Federal Department of Energy Weatherization Assistance Program (DOE WAP)
- State Low-Income Weatherization Program (LIWP)
- Department of Housing and Urban Development (HUD) Lead Hazard Control and Healthy Homes Program
- Utility Company Energy Savings Assistance (ESA) Program
- Utility Company California Alternate Rates for Energy (CARE) Program
Signature of Account Holder
Date
Name of CSD Contractor/Partner Organization
Community Action Partnership of San Bernardino County
OMMUNITY ACTION PARTNERSHIP OF SAN BERNARDINO COUNTY
POLICY MANUAL
Section:
No:
Page 3 of 3
SUBJECT:
CHILD SUPPORT REFERRAL POLICY
Child Support Eligibility Assessment Form
Client indicated that they have custody of their child/children during the Intake screening
process:
Are you the custodial parent/guardian of a child/children?
Yes No
AND
Client did NOT indicate that they are receiving child support as a source of income on the
Income Verification Form
Client is provided with the following information about services provided by the San Bernardino
County Child Support enforcement agency:
Locating a parent
Arranging for paternity testing
Establishing a support order
Enforcing a support order
I, _________________________________________ was given a copy of the Child Support
application
for such services to be submitted to the San Bernardino County Child Support
Enforcement Agency.
======================================================================
CAPSBC employee ___________________________________________provided the
Instructions for completing application for child support services. This form indicates whether a
referral to the Child support enforcement agency was made and information regarding
available services including a contact number for the agency and a copy of the application was
provided to the client.
CAPSBC will indicate services rendered in the case notes completed in the program’s
database tracking software. This form will remain in the client file.
CAPSBC Staff did not act in a manner to be interpreted as giving legal advice but
provided a referral to the custodial parent in the single-parent family contact
information to the state child support enforcement agency below:
Contact information provided 1 (866) 901-3212 and website address: www.childsup.ca.gov
Loma Linda- 10417 Mountain View Avenue- Loma Linda, CA 92354
Ontario – 191 N. Vineyard Avenue – Ontario, CA 91764
Victorville- 15400 Civic Center Drive –Victorville, CA 92392
Client name
Employee name
Lead-Safe
Energy
Mold/Moisture Budget Counseling Radon
Date Time Date Time Date Time
Lead-Safe
Energy
Mold/Moisture Budget Counseling Radon
Date mailed
Self-Certification Option
If the information was delivered but a signature was not obtainable, you may check the appropriate box below.
I certify that I attempted to deliver the following educational information to the dwelling listed above:
Radon Education - A copy of the pamphlet, A Citizen's Guide to Radon , informing me of the potential
risk of radon and how to lower the radon level in my dwelling unit.
State of California
DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT
CSD 321 (Rev. 12/05/11)
CLIENT EDUCATION CONFIRMATION OF RECEIPT
Attempted delivery dates and times
Signature (Agency Representative)
Signature (Agency Representative)
Print name
Mailing Option:
Refusal to Sign — I certify that I have made a good faith effort to deliver the information to the dwelling
unit listed above at the date and time indicated and that the occupant refused to sign the confirmation of
receipt. I further certify that I have left a copy of the information at the unit with the occupant.
Unavailable for Signature — I certify that I have made a good faith effort to deliver the information to
the dwelling unit listed above and that the occupant was unavailable to sign the confirmation of receipt. I
further certify that I have left a copy of the information at the unit by sliding it under the door.
I certify that I have mailed the following educational information to the dwelling listed above (attach copy of
Certificate of Mailing for lead-safe education only):
Print name
Energy Education – Information regarding changes I can make in order to reduce the energy
consumption of my household.
Budget Counseling - Information regarding personal financial management.
I have received the following information:
Date
Signature of Recipient
Mold and Moisture Education - A copy of the pamphlet, A Brief Guide to Mold and Moisture In Your
Home , informing me of how to clean up residential mold problems and how to prevent mold growth.
Confirmation of Receipt
Lead-Safe Education – A copy of the pamphlet, Renovate Right: Important Lead Hazard Information
for Families, Child Care Providers, and Schools , informing me of the potential risk of the lead hazard
exposure from weatherization/renovation activity to be performed in my dwelling unit.
Name of Occupant
Age of Dwelling
Address of Dwelling
X
X
X
X
X
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Community Action Partnership of San Bernardino County INTAKE

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Completed 14 September 2021

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