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.

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.

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.

Please check () one or more boxes

Part I: Household information & composition

Head of the Household Contact Information

Are you a Montgomery County Resident?
Gender (choose one):
Race (choose as many as applies)
Ethnicity (choose one):
Veteran Status (choose one):
Do you have a Physical Disability?
If Yes, is the physical disability expected to be of long-continued and indefinite duration and substantially 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 independently?
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
Ethnicity (choose one):
Gender of Household Member #2 (If applicable)
Race of Household Member #2 (If applicable)
Ethnicity of Household Member #2 (If applicable), choose one:
Gender of Household Member #3 (If applicable)
Race of Household Member #3 (If applicable)
Ethnicity of Household Member #3 (If applicable), choose one:
Gender of Household Member #4 (If applicable)
Race of Household Member #4 (If applicable)
Ethnicity of Household Member #4 (If applicable), choose one:
Gender of Household Member #5 (If applicable)
Race of Household Member #5 (If applicable)
Ethnicity of Household Member #5 (If applicable), choose one:
Gender of Household Member #6 (If applicable)
Race of Household Member #6 (If applicable)
Ethnicity of Household Member #6 (If applicable), choose one:
Gender of Household Member #7 (If applicable)
Race of Household Member #7 (If applicable)
Ethnicity of Household Member #7 (If applicable), choose one:

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 Disability Insurance (SSDI)?
Are you earning VA Service-Connected Disability Compensation?
Are you earning private disability insurance?
Are you earning worker’s compensation?