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.
Part I: Household information & composition
Head of the Household Contact Information
Other Household Members
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.
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.