Fillable Updated Covid App - UWCT FINAL 1

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Updated Covid App - UWCT FINAL 1

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U.S.A. forms for City of Belton, TX

BROWSE CITY OF BELTON, TX (TX) FORMS
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The COVID-19 Response & Recovery Fund is available to help meet the immediate needs of individuals
and families directly impacted by this pandemic.
CRITERIA:
• Individuals/families must have been actively employed at the time of the COVID-19 pandemic, and are
now experiencing income loss as a direct result of the shutdown
• One application per household
• One time only granted assistance
• All documents listed below must be presented
• Applicant must live in Bell County
DOCUMENTS NEEDED:
• Government Issued Photo ID
• Completed COVID-19 Application
• Completed COVID-19 Employment Verification Form
• February Paycheck Stub and Paycheck stub from last 30 days
• Lease Agreement/Mortgage Statement
• Current Utility Bill
TIMELINE/PROCESS
• Completed application received by UWCT
• Application reviewed and decision made within 5 business days
• Higher fund requests may be subject to additional approval and require more time
• Payment made directly to the vendor. No payments made directly to the applicant.
• Applicant receives approval documentation with confirmation of payment to vendor
Submit Completed Application to:
covidrelief@uwct.org
LIMITED FUNDS AVAILABLE!
Please contact covidrelief@uwct.org with any questions.
COVID-19 Community Relief Fund
Application for Individual/Family Assistance
Assistance requested: Housing____ City Utilities____ Other Utilities____ Other____ Referral for other services ____
How did you hear about the UWCT COVID-19 Fund?____________________________________________________
PERSONAL INFORMATION
Applicant Name: ________________________ Co-Applicant Name: _________________________
Address: _______________________________ Address: __________________________________
City: __________ State: _________ Zip:_______ City: __________ State: _________ Zip: _________
Phone: _________________________________ Phone: ___________________________________
Email: __________________________________ Email: ___________________________________
# of people in household:________ Ages:_________________________________________
Weekly Household Income before COVID-19: $__________ Weekly Household Income today: $____________
HOUSEHOLD MEMBERS:
Name
Relation
to
Applicant
Date of
Birth
Age
Gender
Ethnicity-
Hispanic
(Y/N)
Race-
select
number
below
Receives
Income
(Y/N)
Monthly
Amount
Earned
Race—select one (1) and place number in section above.
11 White, 12 Black/African American, 13 Asian, 14 American Indian/Alaska Native, 15 Native Hawaiian/Other Pacific
Islander, 16 American Indian/Alaska Native & White, 17 Asian & White, 18 Black/African American & White,
19 American Indian/Alaska Native & Black/African/American, 20 OTHER MULTI-RACIAL
Employment: Must have employer name & contact information from the job affected by COVID-19.
Applicant Name: ____________________________________________________________________________
Employer Name: ____________________________________________________________________________
Employer Address: __________________________________________________________________________
Company: _________________________________________________________________________________
How long employed: _________________________________________________________________________
Supervisor Contact Name: ____________________________________________________________________
Employer Phone: ________________________________ Employer Email: _______________________________
Impact of COVID-19 to Employment (change in employment status must be the direct result of employer
decisions or government mandates):
Current Job Status: Employed: _____ Reduction of hours: _____ Laid Off: _____ Terminated:____ Other: ______
Effective date of Status Change: _________________________________________________________________
Co-Applicant Name: __________________________________________________________________________
Employer Name: _____________________________________________________________________________
Employer Address: ___________________________________________________________________________
Company: __________________________________________________________________________________
How long employed: __________________________________________________________________________
Supervisor Contact Name: _____________________________________________________________________
Employer Phone: ________________________________ Employer Email: _______________________________
HOUSING ASSISTANCE REQUEST
Landlord/Leasing Agent/Mortgage Company: ______________________________________________________
Phone: _____________________________________________________________________________________
Billing Address: ______________________________________________________________________________
Manger/Landlord Name: _______________________________________ Email: __________________________
Name on Lease or Mortgage: _________________________________ Monthly Payment: __________________
Rent Information:
Do you have a lease?
☐Yes ☐No
How long have you lived there?
Are you behind on your rent/mortgage?
☐Yes ☐No
Monthly Rent $
Due Date:
How much do you owe in back payments?
$
For which months?
Do you owe late fees?
☐Yes ☐No
Do you receive rent assistance?
(i.e. Section 8)
☐Yes ☐No
Type of assistance?
UTILITY ASSISTANCE REQUEST (includes city water bills):
Utility Company or City Utilities: __________________________________________________________________________
How Much?
Billing Address: ________________________________________________________________________________________
Name on Bill: __________________________________________________________________________________________
Have you missed any payments: Do you have any late fees: _____________________________________________________
Current Bill Amount: ___________________________ Amount Past Due: _________________________________________
Are you able to make a partial payment: If yes, how much: _____________________________________________________
Other Assistance Requested (i.e. Child Care, Car Payment, Prescriptions, Other Household Bills):
Please explain request and amount requested: _______________________________________________________________
Have you received assistance for COVID-19 from another source: ________________________________________________
If yes, from where: How much: ____________________________________________________________________________
COVID-19 has affected my household in the following way: (Describe the need for assistance and how the household has been
affected by the COVID-19 pandemic.)
Date: Co
-Applicant’s Signature:
Date:
I hereby certify that the information and statements made on this form and al information furnished in support
of the application for assistance are true and correct to the best of my belief and knowledge. I agree to give
United Way of Central Texas any information necessary to prove statement about my eligibility. I furthermore
give United Way of Central Texas permission to contact my employer, benefit provider, or creditors to verify
information I have provided to establish my eligibility. I understand that this application will be considered
without regard to race, color, religion, creed, national origin, or political belief. I understand if granted
assistance, it is a ONE TIME ONLY GRANTED ASSISTIANCE.
The applicant agrees that this application may be electronically signed. The applicant agrees that the electonic
signature appearing on this application is the same as a handwritten signature for the purpose of validity,
enforceability, and admissibility.
Applicant’s Signature: _______________________ __________________________
_____________________ __________________________
UNITED WAY OF CENTRAL TEXAS
COVID-19 Community Relief Fund
Employment Status Verification
Must be completed by employer. A signed letter from the employer can be substituted.
Today’s Date:
______________________
This statement is to confirm that _____________________________ is/was employed at
______________________________. He/She worked full-time hours of _______ per week or part-
time hours of ______ per week at $___________per hour.
The frequency of payment was:
_______weekly _______bi-weekly _______semi-monthly ________monthly
Status of employment due to COVID - 19 as of today’s date: ______________
_______ Change in employment was not related to COVID-19
_______ Reduction of Hours
_______ Laid Off
_______ Terminated
_______ Other
Other explanation: _________________________________________________________________
Company Name: ___________________________________________________________________
Employer Name: ___________________________________________________________________
Signature of Employer:_______________________________________________________________
Title:______________________________________________________________________________
Address: _____________________________________
_____________________________________
_____________________________________
Phone: _______________________________
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Updated Covid App - UWCT FINAL 1

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Completed 11 July 2020

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