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Overview The CAP CARES Program is a CSBG

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*Assistance based on availability of funds*
Overview
The CAP CARES Program is a CSBG funded program to assist Riverside County families with
emergency assistance to help cover unmet household bills such as water, sewage, garbage, utility
assistance, technology and special needs.
Program Eligibility
Income-qualification is based on 200% of the Federal poverty guidelines and the number of
people in the household.
2020 CSBG CARES Act Poverty Guidelines
Size of Family Unit or
Number in Household
Monthly Income
Annual Income
1
$2,127
$25,520
2
$2,873
$34,480
3
$3,620
$43,440
4
$4,367
$52,400
5
$5,113
$61,360
6
$5,860
$70,320
7
$6,607
$79,280
8
$7,353
$88,240
9+
Add $4,480 for each person over 8
Participant Requirements
Reside in Riverside County
Be 18+ years old
Submit a form of identification (government issued ID, consular identification card, or passport)
Copy of current bills. (No older than 4 weeks).
Application Process
1. Submit CAP Cares application, intake sheet, identification and a copy of the current utility
bill(s) you are requesting assistance with. Eligible bills include water, trash, sewer,
electric, propane, internet.
2. Once your application has been reviewed and approved, an official award letter will be
provided to confirm the payment. Communicate with company, to inform them that all
program requirements under the CAP CARES Program have been met and a payment will
be made on your behalf. Please note that the payment will made directly to the company.
3. A Community Action staff representative may contact you, as a courtesy follow-up and
wellbeing check of you and your family during COVID-19. Regular follow-ups may take
place for the duration the recovery period through May 2022.
Community Action Partnership
CAP CARES Program
Section 1 Applicant Information
Full Name:
Last
First
Address:
Street Address
Apartment/Unit #
City
State
ZIP Code
Social Security #:
Date of Birth: Phone:
Email: How did you hear about CAP:
Which service/services would you require assistance for: Utilities: Technology: Other:
Section 2 Household
Total number of persons living in household including applicant:
*Please include separate sheet for additional household members
Full Name:
Relationship to Client:
Age:
Full Name:
Relationship to Client:
Age:
Full Name:
Relationship to Client:
Age:
Section 3 Applicant Signature
Applicant Signature:
Date:
Witness Signature:
Agency Approval
Approved: Yes No
Amount:
Management Approval
Intake Staff Name (Print)
Date
Project Code Number:
Community Action Cares
Intake Application
1. I hereby authorize the Community Action Partnership (CAP) to examine all employment, income, utility, and other records
pertinent to my application for assistance.
2. I hereby authorize the release of information regarding my bills past and future, to CAP.
3. I certify under penalty of perjury that all information herein is true and correct to the best of my knowledge.
4. I agree to be contacted monthly to share information about the wellbeing of my family during COVID -19 and during the
recovery period until May 2022.
5. I certify that the total household income for the above individual does/does not (circle one) exceed the established poverty
guidelines indicated above.
Customer Intake Form
CUSTOMER INFORMATION
Last Name
First Name
Date of Birth
Today’s Date
Phone
( )
Email
SSN
Office Location
Address
City
Zip Code
GENDER
MARITAL STATUS
ETHNICITY
☐ Male
☐ Female
☐ Other
☐ Single
☐ Married
☐ Domestic Partner
☐ Separated
☐ Divorced
☐ Widowed
☐ Hispanic/Latino
☐ Non-Hispanic/Latino
INDICATE YOUR RACE (SELECT ONE)
☐ American Indian/Alaskan Native
☐ Asian
☐ Black/African American
☐ Caucasian (White)
☐ Hawaiian/Pacific Islander
☐ Multi-Race
☐ Other
☐ Unspecified
INDICATE YOUR EDUCATION (SELECT ONE)
☐ 0-8
th
Grade
☐ 12+ Some Postsecondary
☐ 2 Year Degree
☐ 4 Year Degree
☐ 9-12 Education
☐ GED
☐ Graduate Degree
☐ High School Graduate
☐ Unspecified
☐ Vocational School
INDICATE YOUR HEALTH INSURANCE (SELECT ONE)
☐ No Health Insurance
☐ Direct Purchase
☐ Employment Based
☐ Medi-Cal
☐ Medicare
☐ Military Health Care
☐ State Children’s Health Insurance
☐ State Insurance for Adults
☐ Unknown
MILITARY STATUS (SELECT ONE)
DO YOU RECEIVE FOOD STAMPS?
ARE YOU DISABLED?
☐ Active Military
☐ Veteran
☐ No Military
☐ Yes
☐ No
☐ Decline to Answer
☐ Yes
☐ No
☐ Decline to Answer
FARMER (SELECT ONE)
WORK STATUS (SELECT ONE)
☐ Farmer
☐ Migrant
☐ Migrant Seasonal
☐ Not a Farmer
☐ Employed Full-Time
☐ Employed Part-Time
☐ Migrant Seasonal Farm Worker
☐ Retired
☐ Unemployed (Long-Term)
☐ Unemployed (Not in Workforce
☐ Unemployed Short Term >6mos
☐ Unknown
DO YOU RECEIVE WIC? (SELECT ONE)
NON-CASH BENEFITS (SELECT ONE)
☐ Yes
☐ No
☐ Unknown
☐ Affordable Care Act Subsidy
☐ Childcare Voucher
☐ Housing Choice Voucher
☐ Public Housing
☐ CalFresh/Food Stamps
☐ LIHEAP
☐ None
☐ Other
☐ Permanent Supportive Housing
☐ WIC
INDICATE YOUR MONTHLY INCOME AMOUNT AND SELECT INCOME SOURCE:
$
☐ Employment
☐ TANF
☐ Public Assistance
☐ Child Support
☐ Self-Employment
☐ Unemployment Insurance
☐ Pension
☐ Alimony
☐ Rental
☐ EITC
☐ Work Comp
☐ Private Disability Insurance
☐ Social Security
☐ Retirement Social Security
☐ SSDI
☐ SSI
☐ VA Service - Disability
☐ VA Non-Service - Disability
HOUSING STATUS (SELECT ONE)
☐ Rent
☐ Own
☐ Own - Multi-Family
☐ Own - Mobile Home
☐ Other
☐ Homeless
☐ Runaway
☐ Temp Stable
☐ Temp Unstable
Please complete this side of the form for any additional members of your household.
06-20-17 VW
Marital
Status
Relation to
Applicant
Ethnicity
Race
Education
Health Insurance
Source of Income
A. Single
B. Married
C. Domestic
Partner
D. Divorced
E. Separated
A. Brother
B. Child
C. Father
D. Foster Child
E. Foster Parent
F. Friend
G. Grandchild
H. Grandparent
I. Mother
J. Other
K. Other Related
L. Other Relative
M. Sister
N. Spouse
O. Stepfather
P. Stepmother
A. Hispanic
or Latino
B. Non-
Hispanic or
Non-Latino
A. American Indian
or Alaskan Native
B. Asian
C. Black/African
American
D. Caucasian (White)
E. Hawaiian/Pacific
Islander
F. Multi-Race
G. Other
If household member
is over age of 18
indicate highest
grade completed
A. 0-8th grade
B. 9-12th grade
C. High School Grad
D. GED
E. 12 + some
secondary school
F. 2 -year College
graduate
G. 4-year College
graduate
H. N/C Child under
age of 18
Please indicate your source of
Health Insurance
A. No Health Insurance
B. Direct Purchase
C. Employment Based
D. Medical
E. Medicare
F. Military Health Care
G. State Children’s Health
Insurance
H. State Insurance for Adults
I. Unknown
Please indicate your source of
income
A. Employment
B. TANF
C. Public Assistance
D. Self-Employment
E. Alimony
F. Child Support
G. Interest/Dividends
H. Pension
I. Rental
J. Social Security
K. SSDA
L. SSI
M. Veterans
N. Work Comp
Customer Information
Using the key below please answer the
following questions
Using (Y) for Yes or (N) for No
please answer the following
Income
First Name
Last Name
Date of
Birth
Male or
Female
Marital
Status
Relation to
Applicant
Ethnicity
Race
Education
Health
Insurance
Served in
Military
Food
Stamps
WIC
Disabled
Farmer
Income
Source of
Income
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Completed 11 January 2021

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