Rent and Utility Emergency Assistance Application & Self-Certification Form

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The United Way of the Ouachitas rent and utility emergency assistance program is being assisted with federal Community Development Block Grant CARES Act (CDBG-CV) funds from the City of Hot Springs. We are asking for your cooperation in completing this form to verify your eligibility for benefits. Please be assured that this information will be used to meet the record keeping requirements of the U.S. Department of Housing and Urban Development (HUD) Community Development Block Grant (CDBG) and the Charity Tracker shared, computerized record keeping system that captures information about people experiencing need for emergency services such as rent and utility assistance.

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ASSISTANCE ELIGIBILITY BASICS

Before applying, please consider the basic criteria that will be used to determine your household’s eligibility to receive rent and/or utility assistance:
  • You must live inside Hot Springs city limits; and
  • Your household cannot earn more than the HUD median low- to moderate-income thresholds for the CDBG program (see table below); and
  • Your household must have been impacted by a COVID-19 related hardship; and
  • Your rental agreement (lease) and/or utility bills are in the name of someone living in the household; and
  • You must be able to provide documentation to prove all of the above and the financial need for rent and/or utility emergency assistance

Current HUD CDBG Area Median Income Limits (subject to change without advanced notice)

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Eligibility

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DOCUMENTS TO INCLUDE WITH YOUR APPLICATION

Providing the following documents with your application will help speed up the review process. If you prefer to have your application reviewed first and send the supporting documentation later, we understand, but realize that any delay in providing documents will delay our ability to review and qualify your application.
  1. Copy of the Head of Household Drivers’ License or other Federal/State Photo ID such as a work or school identification card, identification card for health benefits or other assistance, military ID, etc.
  2. Copy of last month’s pay check stubs and assistance and benefits documents for all income and persons including the name of the person and amount received
  3. Copy of the rental agreement (lease)
  4. Rent assistance: Copy of any written communication with the landlord regarding acceptance of partial payments during the eviction moratoriums; receipts or cancelled checks showing full or partial payments made over the last 3 months; copy of an eviction notice, if applicable
  5. Utilities assistance: Current bill showing past due or due amounts; receipts or cancelled checks showing full or partial payments made over the last 3 months; copy of any shutoff notice, if applicable
  6. Copy of all documentation needed to demonstrate a COVID-19 related hardship
  7. YOU WILL LIKELY BE ASKED FOR ADDITIONAL DOCUMENTATION DURING APPLICATION REVIEW. FAILURE TO PROVIDE DOCUMENTATION WILL RESULT IN DELAYS OR APPLICATION REJECTION.

Document Uploads
such as a work or school identification card, identification card for health benefits or other assistance, military ID, etc.
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Upload last month’s pay check stubs and assistance and benefits documents for all income and persons including the name of the person and amount received.
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Copy of any written communication with the landlord regarding acceptance of partial payments during the eviction moratoriums; receipts or cancelled checks showing full or partial payments made over the last 3 months; copy of an eviction notice, if applicable
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Current bill showing past due or due amounts; receipts or cancelled checks showing full or partial payments made over the last 3 months; copy of any shutoff notice, if applicable
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Head of Household
$
Include wages, salary, overtime, hazard pay, commissions, tips, bonuses, unemployment compensation, severance pay, interest, dividends, net income from business and self-employment including gig economy jobs (e.g. Uber, Etsy, etc.), social security, retirement/pension, disability or death benefits, welfare assistance payments, VA benefits, alimony or child support, re-occurring cash gifts from private/nonprofit charity or friends/family who do not reside with you.
$
Assistance Requested
$
$
$
$
$
$
$
$
Rent/Utility Assistance Applied for or Received to Date

Have you applied for or received any rent and utility assistance since March of 2020? Please note that the organizations listed may or may not have funding at this time; the list is provided for convenience.

Community Services Office (CSO) Funding
$
Charitable Christian Ministries and Clinic (CCMC)
$
Ouachita Children, Youth & Family Svcs (OCYFS)
$
Salvation Army
$
United Way
$
Ouachita Behavioral Health & Wellness
$
Other
$

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ALL HOUSEHOLD MEMBERS (Including Yourself)

Please complete the next section for all members of your household including those that may be living with you full time that are not related. Please remember to include yourself on the first line.

Disability is an optional question. A severe disability is defined by HUD as using a wheelchair or another special aid for six months or longer; or if you are unable to perform one or more functional activities such as seeing, hearing, having one’s speech understood, lifting and carrying, walking up a flight of stairs; or if you need assistance with an activity of daily living which includes getting around inside the home, getting in or out of bed or a chair, bathing, dressing, eating or toileting; or need assistance with an instrumental activity of daily living such as going outside the home, keeping track of money or bills, preparing meals, doing light housework or using the telephone; or have a selected condition including autism, cerebral palsy, Alzheimer’s disease, senility, etc.

Race is an optional question. Answers may include, but are not limited to White, Black/African American, American Indian, Alaskan Native, Asian, Native Hawaiian, Other Pacific Islander, Multi-Racial or other.

Household Member #1 (Head of Household/Self)
Household Member #2
Household Member #3
Household Member #4
Household Member #5
Household Member #6
Household Member #7
Household Member #8

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HOUSEHOLD INCOME


Please include copies of last month’s proof of income/paystubs

Please list all household income. Include wages, salary, overtime, hazard pay, commissions, tips, bonuses, unemployment compensation, severance pay, interest, dividends, net income from business and self- employment including gig jobs (e.g. Uber, Etsy, etc.), Social Security Income, Supplemental Security Income (SSI), Supplemental Security Disability Income (SSDI), retirement/pension, disability or death benefits, welfare assistance payments, Veteran’s benefits, alimony, child support, TEA, Housing Choice/Section 8 assistance, housing utility assistance payments, re-occurring cash gifts from private/nonprofit charity or friends/family who do not reside with you.

Household Income Source #1
$
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Household Income Source #2
$
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Household Income Source #3
$
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Household Income Source #4
$
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Household Income Source #5
$
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Household Income Source #6
$
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Household Income Source #7
$
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Household Income Source #8
$
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Household Income Source #9
$
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Household Income Source #10
$
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Cash
$
Bank Account #1
$
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Bank Account #2
$
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Bank Account #3
$
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Bank Account #4
$
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Bank Account #5
$
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Job Loss
$
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$
Furlough
$
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$
Reduced Hours
$
Upload requirements
$
Unpaid Time Off for Self-Isolation, Quarantine or COVID-19 illness
$
Upload requirements
$
Unpaid Time Off to care for a child under the age of 18
$
Upload requirements
$
Loss of a Member of the Household to COVID-19
$
Eviction
Upload requirements
$
$

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CERTIFICATIONS


I certify under penalty of perjury that the above information is complete and accurate to the best of my knowledge. I understand that Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government. I further understand that any willful misstatement of information will be grounds for disqualification and barring of any future assistance. I agree to provide any additional documentation required by the program administer to determine eligibility for program assistance. I agree to provide documentation needed to assist in determining eligibility. I hereby waive my/our rights under the privacy and confidentiality provision act, and give my/our consent to the City of Hot Springs, United Way of the Ouachitas, the U.S. Department of Housing and Urban Development, Office of the Inspector General or their authorized agents to examine any information given herein.

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RELEASE OF INFORMATION

Ouachitas Assistance Network
Shared Case Management Software – Charity Tracker
RELEASE OF INFORMATION (ROI)

The Ouachitas Assistance Network, hereinafter referred to as “CharityTracker”, is a shared, computerized record keeping system that captures information about people experiencing need for emergency services, including but not limited to assistance with utility bills, medications, food, rent/mortgage payments, etc. United Way of the Ouachitas (Administering Agency) administers CharityTracker on behalf of participating agencies of the CharityTracker Assistance Network.

I understand that all information gathered about me is personal and private and that I do not have to participate in CharityTracker. I have had an opportunity to ask questions about CharityTracker and to review the basic identifying information, which is authorized by this release for the CharityTracker Assistance Network Participating Agencies to share. I also understand that information about non-confidential services provided to me by CharityTracker participating agencies may be shared with other CharityTracker Participating Agencies. This Release of Information will remain in effect for 3 years from the date noted under my signature at the bottom of this page unless I make a formal request this this Organization that I no longer wish to participate in CharityTracker.

Dependent’s Name              Relationship            Age

I authorize United Way of the Ouachitas, as a CharityTracker Participating Agency, to share my basic, identifying and non-confidential service transactions/information with other CharityTracker Participating Agencies. I authorize the use of a copy of this original to serve as an original for the purposes stated above. I further authorize United Way of the Ouachitas as a Charity Tracker Participating Agency, to share my dependent’s basic, identifying and non-confidential service transactions/information with other CharityTracker participating agencies.