Fillable Emergency Services Online Application 1

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Emergency Services Online Application 1

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6323 Manchester Avenue • Kansas City, Missouri 64133 • Phone: 816.358.6868 • Fax: 816.203.4371
www.caagkc.org
Dear Customer,
This letter is in response to your request for emergency assistance.
Community Action Agency of Greater Kansas City (CAAGKC) provides Family Supportive Services to
stabilize individuals and families in crises. Services include, but are not limited to: emergency
rental assistance and emergency water assistance only. We believe in providing assistance to
individuals and families in crises that demonstrate a need.
Enclosed, you will find the following documents:
• CAAGKC Acknowledgment and Consent Forms
• CAAGKC Intake Application (Family Intake Assessment and Referral Form)
• Statement of Hardship and Need
• Self-Declaration of Zero Income Form
• Declaration of Homelessness Form
Please keep the following in mind as you complete these forms:
• Drop-off applications will not be accepted at this time.
• All information is confidential and will be kept securely within our organization.
• Email us at directassistance@caagkc.org
if you have questions about completing these forms.
• Carefully read and complete each form; missing or incomplete information will result in an
“Unable to Assist” determination.
After you have completed and saved the required documents (see Rental/Mortgage and Utility
Assistance Checklist on page 2), please notify us via email at directassistance@caagkc.org. A CAAGKC
staff member will email you a secure link you can use to upload a copy of your current Photo I.D.,
Social Security card, and completed application packet.
Please ensure all required documents are included at the time of submittal. Applications will be
reviewed in the order they are received. Again, please note there will be no drop-off applications
accepted at this time; incomplete application packets will result in an “Unable to Assist” determination.
Sincerely,
Lamont Hale, Director of Programs
6323 Manchester Avenue • Kansas City, Missouri 64133 • Phone: 816.358.6868 • Fax: 816.203.4371
www.caagkc.org
Rental/Mortgage and Utility Assistance Checklist
All documents must be completed and submitted to CAAGKC before the application can be processed.
Incomplete application packets will result in an “Unable to Assist” determination.
CAAGKC Intake Application (Family Intake Assessment and Referral Form) *required for all applications
• Customer must report income for ALL household members for the month prior (e.g., if you
request assistance in May, report your income for the month of April). Economic Impact
Payments (received from the U.S. Treasury Department during the 2020 corona virus pandemic)
are NOT considered income; do not report this amount as “Other Income.”
• Household gross income cannot exceed 200% of Federal Poverty Guidelines.
CAAGKC Acknowledgment and Consent Forms *required for all applications
Statement of Hardship and Need *required for all applications
Proof of Current Photo I.D. for Applicant *required for all applications
Proof of Social Security card for Applicant *required for all applications
Self-Declaration of Zero Income Form *only required if household has no income for the month prior
Declaration of Homelessness Form *only required if applicant is homeless and seeking Rental Assistance
Check this box if you are requesting Rental Assistance
• A copy of your lease agreement and delinquency notice is required. Lease agreement must be
complete with all pages attached, have the customer’s name on the lease agreement, and show
the base rent amount – NO EXCEPTIONS. CAAGKC does not provide assistance with monthly
rent for subsidized housing (i.e., Section 8 or Housing Choice voucher programs).
• CAAGKC does not provide assistance for sublet leases or room rent. The lease agreement must
be between the customer and the “lessor” (i.e., landlord, property management company, or
individual owner of the property).
• Property owner/Mortgage holder must agree to accept payment from CAAGKC on the
customer’s behalf; agree to extend housing to the customer for at least 30 days; and submit a
current I.R.S. Form W-9 to CAAGKC.
• Assistance requests for first month’s rent/deposit must include a signed lease agreement.
Check this box if you are requesting Utility Assistance
• A copy of your utility bill is required. Utility bill must be in the customer’s name. Customer must
reside at service address listed on utility bill. Customer’s utility account must be active (no old
bills or charge offs).
Ackno
wledgment and Consent Forms
Revised: 04/21/2020 Page 1 of 2 P:\SUPPORTIVE SERVICES\CV-19\Forms\CAAGKC consent forms_CV-19.pdf
CLIENT CONFIDENTIALITY / RELEASE OF INFORMATION ACKNOWLEDGEMENT AGREEMENT
Under the terms of this Agreement, CLIENT agrees to release to CAAGKC information that is confidential and
proprietary to CLIENT - Confidential Information to be used solely for the Agency’s related statistics, services and
programs. Confidential Information refers to any and all information of a confidential, proprietary, or secret
nature which is or may be related in any way to the family, medical records, job history, present or future, of
CLIENT or any related data. Confidential Information includes, for example, but not limited to: spouses or other
family members, ages, salaries, financial standings, criminal records, medical records and all other pertaining to
the family information. CAAGKC will consider all information received from CLIENT to be strictly confidential, as
required by the Privacy Act, and subject to the restrictions of this Agreement; except for information that is (i)
generally known to the public, (ii) in the possession of CAAGKC before receipt from the CLIENT, (iii) obtained later
by the Agency from a third party without restriction on violation of Agreements.
CAAGKC
will not disclose CLIENTS Confidential Information to any party without the prior written consent of
CLIENT. CAAGKC may, however, disclose Confidential Information to its employees and/or programs but only if
the employee has a legitimate need to know and has agreed to terms similar to those in this Agreement.
Community Action Agency may also disclose this Confidential Information (i) to medical personnel in an
emergency; (ii) to qualified personnel for research, audits, or program evaluation, as long as CLIENT identities are
not identified; (iii) to a third party based on court orders; and (iv) to appropriate authorities in cases of suspected
child abuse or neglect. CAAGKC will be responsible for any use or disclosure of Confidential Information by any of
its employees or agents to third parties who should not share this information.
_____YES ______NO
PHOTO, VIDEO, MEDIA RELEASE ACKNOWLEDGEMENT AGREEMENT
I hereby give Community Action Agency of Greater Kansas City (CAAGKC) permission to interview, videotape, or
photograph me with the purpose of using said words or images in the media, in agency publications such as
newsletters, brochures, and advertisements, or other printed or broadcast material. I understand that portions of
my words, photos, or video may be edited or altered by CAAGKC or the news media without my expressed
knowledge or approval. I hereby waive the right to receive any payment for signing this release and waive the
right to receive any payment for CAAGKC use of any right to inspect or approve finished photographs, audio,
video, multimedia, or advertising recordings and copy or printed matter or computer generated scanned image
and other electronic media that may be used in conjunction therewith or to approve the eventual use that it
might be applied.
_____YES ______NO
Revised: 05/06/2020 Page 2 of 2 P:\SUPPORTIVE SERVICES\CV-19\Forms\CAAGKC consent forms_CV-19.pdf
CUSTOMER GRIEVANCE/COMPLAINT POLICY ACKNOWLEDGEMENT AGREEMENT
Community Action Agency of Greater Kansas City customers are treated fairly without regard to race, color, sex,
national origin/ancestry, religion, disability, veteran status, and any other characteristic protected by applicable
affirmation laws. It is our intent to provide professional services to customers who apply for individual programs
we administer. If a customer has a grievance/complaint he/she should immediately contact the manager of the
program involved for resolution. Contact information will be provided by the Receptionist of CAAGKC.
_____YES ______NO
________________________
Date
_____________________
Date
CV-19, Customer verbal attestation
Participant Signature
__________________________________________
CAAGKC Staff Signature
__________________________________________
Participant Name
Family Intake Assessment and Referral Form
Page 1 of 1
Revised: 12/14/2020
P:\SUPPORTIVE SERVICES\CV-19\Forms\FIAR (1pg Intake) Form_CV-19.pdf
EXPLANATION OF ABBREVIATIONS & TERMS LISTED BELOW:
REL: Relationship to Head of Household Race: (B) Black (W) White (AI) American Indian (O) Other (OI) Other Islander (A) Asian
Head of Household Name
REL
Race
Education
Disabled
Insurance
Gender
Social Security #
Date of Birth
1.
SELF
Last Grade Completed:
Y
es
Check all that apply:
Email:
Home Address City
State
Ethnicity
MO
Hispanic/Latino: Yes No
Phone
Housing - Please Check One
Benefits
Yes No
SNAP / Food Stamps:
List all monthly income (before taxes) & sources of income in the household: $
Wages
SSI/SSA
TANF Pension
Unemployment Child Support Other Income
Other Household Member Name
REL
Race
Education
Disabled
Insurance
Gender
Social Security #
Date of Birth
2.
Last Grade Completed:
Check all that apply:
3.
Last Grade Completed:
Check all that apply:
4.
Last Grade Completed:
Check all that apply:
5.
Last Grade Completed:
Check all that apply:
6.
Last Grade Completed:
Check all that apply:
7.
Last Grade Completed:
Check all that apply:
Do you need help with any of the following? Check all that apply (Yes/No)
Utilities?
Housing?
Are you a custodial/single parent?
Child Care?
Transportation?
I understand the information provided is subject to verification and I further realize that falsified or fraudulent information may result in the rejection of my application. I
authorize this agency; their agents and employees to receive or provide information for the purpose of completing the application and hereby release the foregoing of and
from any liability for services provided. I consent to the release of pertinent information to concerned social service agencies and vendors as necessary to c
omplete services
for my household or to provide statistics on emergency assistance or as a guard against duplication of assistance. I hereby authorize my fuel supplier or other vendors
related to my household to release information concerning my fuel or other accounts as necessary to ensure timely processing of this application. I acknowledge, by my
verbal consent, the information entered on this form is true and correct to the best of my knowledge.
Date:
Staff's Signature:
Date:
OFFICE USE - Please list referrals:
1.
2.
Annual Income:
Monthly Total
x =
3.
4.
5. 6.
Medicaid Private
Medicare MC+
None
No
ZIP Code
Own Rent Homeless
Public Housing Other
No
Yes Amount:
Yes No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Medicaid Private
Medicare MC+
None
Medicaid Private
Medicare MC+
None
Medicaid Private
Medicare MC+
None
Medicaid Private
Medicare MC+
None
Medicaid Private
Medicare MC+
None
Medicaid Private
Medicare MC+
None
*Is any member in the household a veteran?
*Has your residence been weatherized?
Applicant's Signature:
Employment/Education?
Unmet health needs?
Food Assistance?
Other?
|
|
|
|
(Please check one of the following.)
Yes
No
0.00
$0.00
12
$ 0.00
click to sign
signature
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Statement of Hardship and Need
Date:
First Name:
Last Name:
Case Manager Name:
(if applicable)
What type of assistance are you requesting?
Clearly and concisely explain the reason(s) for
your hardship. What caused you to fall behind (i.e.,
serious illness, lay-off, permanent or short-term disability)?
P:\SUPPORTIVE SERVICES\CV-19\Forms\Statement of Hardship and Need_CV-19.pdf
Revised: 04/29/2020
Revised: 04/22/2020
P:\SUPPORTIVE SERVICES\CV-19\Forms\Self-Declaration of Zero Income Form__CV-19.pdf
SELF-DECLARATION OF ZERO INCOME FORM
I certify that I do not receive income from any of the following sources:
• Wages from employment
• Income from operation of a business
• Rental income from real or personal property
• Interest or dividend from assets
• Supplemental Security Income (SSI), Social Security payments, annuities, insurance
policies, retirement funds, pensions, or death benefits
• Unemployment or disability payments
• Public assistance payments
• Periodic allowances such as alimony, child support, or gifts from persons not living in
my household
• Sales from self-employment resources
• Any other income sources not listed above
I certify that the information presented in this certification is true and correct to the best of my
knowledge. I understand that falsified or fraudulent information may result in the rejection of
my application. I further understand that by signing this certification and knowingly giving
false information constitutes an act of fraud.
Head/Member of Household Name
CV-19, Customer verbal attestation
Head/Member of Household Signature Date
Staff Signature Date
Revised: 05/06/2020
P:\SUPPORTIVE SERVICES\CV19\Forms\Declaration of Homelessness_CV-19.pdf
Declaration of Homelessness
Participant Name (print):
Date of Birth:
Check the appropriate type of documentation used to verify homelessness and attach it to this
worksheet. Maintain all documents in participant file.
Homeless Status
Type of Documentation
Documentation Attached
Persons living on the street
A signed and dated general certification from an
outreach worker verifying that the services are
going to homeless persons, and indicates where
the persons served reside.
Persons coming from living on
the street (and into a place
meant for human habitation)
Staff should provide written information obtained
from third party regarding the participant’s
whereabouts, and then sign and date the
statement.
Persons coming from
emergency shelter for
homeless persons
Written referral from the external agency.
Persons coming from
transitional housing for
homeless persons
Written verifications to include program
residency and homeless status prior to program
entry.
Persons coming from a
housed-homeless situation
Written verifications to include name, address,
phone number and signature of person(s)
providing temporary accommodation.
Persons being evicted from a
private dwelling
Documentation of income, efforts to obtain
housing, why participant would be on the street,
and either documentation of formal eviction
proceedings or statement from family evicting
participant.
Persons from a short-term
stay in an institution who
previously resided on the
street or in an emergency
shelter
Written verification from the institution’s staff that
the participant has been residing in the
institution for less than 31 days; and information
on the previous living situation.
Persons being discharged
from a longer stay in an
institution
Written verification from the institution of
discharge within one week of receiving
homeless assistance AND documentation of
income, efforts to obtain housing, and why
person would be homeless without assistance.
Confidential situation
Written, signed and dated verification from the
participant.
Participant Signature:
CV-19, Customer verbal attestation
Staff Signature:
Date:
Date:
Notes:
Yes No N/A
Yes No N/A
Yes No N/A
Yes No N/A
Yes No N/A
Yes No N/A
Yes No N/A
Yes No N/A
Yes No N/A
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Completed 1 December 2021

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