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Your Way Home Emergency Rent & Utility Coalition Intake Application

This data is collected for purposes of assessing initial intake and eligibility for the Your Way Home Emergency Rent and Utility Coalition’s program in response to COVID‐19, called ERUC‐CV. The information contained in this form will be input into Montgomery County’s Homeless Management Information System (HMIS), Clarity, with your signed permission. If you permit it, this agency may share limited information about you with other Your Way Home Montgomery County (YWH) agencies from whom you may also seek services. We will not deny you help if you do not want us to share your personally identifying information.

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Additionally, this is a written statement from the beneficiary documenting monthly (Gross) Income at time of application, the number of beneficiary members in the family or household, and the relevant characteristics of each member for the purposes of income determination. For the purposes of this regulation, income will be defined according to the Code of Federal Regulations at 24 CFR, Part 5.

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The information provided on this form is subject to verification at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated or. knowingly and willingly making a false or fraudulent statement to a department of the United States Government. All adult beneficiary members must then sign this statement to certify that the information is complete and accurate, and that source documentation will be provided upon request.

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Please check () one or more boxes
Part I: Household information & composition
Head of the Household Contact Information
Are you a Montgomery County Resident
Gender
Race (choose as many as applies)
Ethnicity
Veteran Status
Do you have a Physical Disability?
If Yes, is the physical disability expected to be of long-continues and indefinite duration and substantially impair your ability to live independently?
Do you have a Developmental Disability?
If Yes, is the developmental disability expected to impair your ability to live independently?
Do you have a Chronic Health Condition?
If Yes, is the chronic health condition expected to be of long-continued and indefinite duration and substantially impair your ability to live independently?
Do you have HIV/AIDS?
If Yes, is the HIV?AIDS expected to substantially impair your ability to live independently?
Do you have a Mental Health Condition?
If Yes, is the Mental Health Condition expected to be of long-continued and indefinite duration and substantially impair your ability to live indepently?
Do you have a Substance Abuse Condition?
If Yes for Alcohol Abuse, Drug Abuse, or both, is the substance use condition expected to be of long-continued and indefinite duration and substantially impair your ability to live independently?
Are you a Domestic Violence Victim or Survivor?
If Yes, when did the experience occur?
If Yes, are you currently fleeing?
How long have you been sleeping at the location you wrote in above?
Are you currently covered by Health Insurance?
Please check the box for your health insurance choice. Leave blank for ‘no’ for sources that have been terminated, even if you received it in the past
Do you currently receive any non-cash public benefits from any source?
Please check the box if yes for each non-cash benefit choice. Leave blank for sources that have been terminated, even if you received it in the past

Other Household Members

Gender
Race (choose as many as applies)
Ethnicity
Gender
Race (choose as many as applies)
Ethnicity
Gender
Race (choose as many as applies)
Ethnicity
Gender
Race (choose as many as applies)
Ethnicity
Gender
Race (choose as many as applies)
Ethnicity
Gender
Race (choose as many as applies)
Ethnicity
Gender
Race (choose as many as applies)
Ethnicity

Landlord Information

Have you informed your landlord that you have applied for this program?
Do you or your landlord currently receive any rental or utility subsidy for the address on this application (e.g., Housing Choice Voucher AKA "Section 8")?

PART II: Household Income
Head of Household and Other Adults in the Household

Only report on regular, recurrent income sources that are current as of today (i.e. not terminated). Include any income received to your household that a minor receives (e.g. SSI), however income from employment of a minor can be excluded.

Do you or any other Adult Household Member have any current income from any source?

If Yes, enter the monthly amount received based on current income at time of application. If unsure of exact monthly amount, enter your best estimate. Answer ‘No’ for sources that have been terminated, even if they were received in the past.

Are you earning employment income?
Are you earning unemployment insurance?
Are you earning supplemental security income (SSI)?
Are you earning Social Security Disability Insurance (SSDI)?
Are you earning VA Service-Connected Disability Compensation?
Are you earning private disability insurance?
Are you earning worker's compensation?
Are you earning temporary assistance for needy families (TANF)?
Are you receiving general assistance (GA)?
Are you receiving retirement income from social security?
Are you receiving pension or retirement income from a former job?
Are you receiving child support?
Are you receiving alimony or other spousal support?

PART III: COVID-Related Need

Other Household Members

Check as many boxes as appropriate

Rent & Utility Assistance Needed

Did COVID-19 affect your ability to pay your rent or utilities and are you in jeopardy of losing your housing as a result? CADCOM is working with Your Way Home, in the program, the Your Way Home Emergency Rent and Utility Coalition Program, which may provide some assistance to you. Details of this new program are below and you are required to complete the ERUC Prescreen Questionnaire to determine your eligibility.

Your Way Home Emergency Rent and Utility Coalition

Your Way Home Emergency Rent and Utility Coalition

The Montgomery County ERUC program is designed to provide housing stability to hundreds of low- and moderate-income Montgomery County residents at risk of eviction and/or homelessness as a result of COVID-19. This program is an expansion of programs and services offered through Your Way Home, a public-private partnership that since 2014 has helped end and prevent homelessness for thousands of Montgomery County residents.

For a household to be eligible for the ERUC-CV program, it must meet the below requirements:

 

  1. Household must reside in Montgomery County at the time of application, AND

  2. One or more individuals in the household qualified for unemployment benefits or experienced a reduction in household income, incurred significant costs, or experienced other financial hardship directly or indirectly due to the COVID-19 pandemic, AND

  3. The household can demonstrate a risk of homelessness or housing instability, AND

  4. Household must be at or below 80% of Area Median Income at the time of application.

    1. Income eligibility will be based on average gross income over the 30 days preceding the time of assistance.

    2. Income includes earned income, child support, welfare benefits, SSI, SSDI, unemployment income, workman’s comp, pension/investments/401K.

    3. 80% Area Median Income is as follows:
      1 person: $54,150
      2 persons: $61,850
      3 persons: $69,600
      4 persons: $77,300
      5 persons: $83,500
      6 persons: $89,700
      7 persons: $95,900
      ​      8 persons: $102,050

Due to these COVID-19 impacts, I need assistance with (choose one):
I have arrengements owed for the following Utilities

Duplication of benefits affidavit

Section 312 of the Robert T. Stafford Disaster Relief and Emergency Assistance Act, (42 U.S.C.

5121–5207) (Stafford Act)

 

Recipient agrees that if they receive further federal benefits for the same services received under this ERUC‐CV program, the recipient will report receiving benefits within one (1) month of receipt of additional proceeds and/or benefits. If recipient fails to report additional federal benefits, then the County of Montgomery may require immediate repayment in full of the entire grant amount provided by the County of Montgomery.

Since March 1, 2020, have you or any other adult member of your household received rental or utility assistance for the address on this application, from any other source?

PART IV: Certification

I/We HEREBY affirm and verify that I/We have not received payment or other financial assistance that would create a duplication of benefits under this grant program.
 

I/we certify that this information is complete and accurate. I/we agree to provide, upon request, documentation on all income sources. I acknowledge that I understand that making the certification is under penalty of perjury and intentional misrepresentation in self‐certifying that I may call in one or more of these categories is fraud.


Additionally, when you sign this form, it shows that you understand the following:​

  • Persons with access to Your Way Home (YWH) Data Systems are trained in security protocols to protect your data and are only permitted to view your data when you are specifically working with their agency.

  • If you request services from another YWH agency, your information will be shared for referral purposes only.

  • YWH may use information derived from your data to create reports to share with funders, the community, and partners to better understand the scope of homelessness and the services being provided. Your personally-identifying information will never be used on these reports.

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By Signing this form, I/we agree to the following statements:

  • I/we will communicate with my case manager regularly and in a timely fashion.

  • I/we will collaborate with my case manager, my landlord, and my utility companies, to secure and provide all necessary documentation.

  • I/we have received, read, and agree to the Rights and Responsibilities page.

  • I/we have received, read and understand the Grievance Procedure page should my application be denied.

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I/we further understand that failure to comply with the above mentioned statements could result in the following:

  • A delay in receiving the necessary Emergency Rental Assistance.

  • A denial in my application.

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I/we agree with the terms and requirements to receive Emergency Rental and Utilities Assistance. I/we also understand that providing false information may result in disqualification or termination from the program.

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I/we understand that this is not an entitlement program. Decisions on participation are based on a review of information about a household and whether that household meets the criteria that are outlined in the federal program regulations, and the availability of funds.

**If household is unable to digitally or physically sign certification, this certifies that the

household provided verbal certification to the agency providing services:

Your content has been submitted

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