manger
Resume:
Referred by: Govt. Agency Church Other
Private Agency Friend
Name:
Phone:
Address: Email:
Age: DOB:
Sex: Male Female
SSN(last
four): XXX-XX-
New or Returning Client? New Returning Last Date Seen: Veteran in the Household? Yes No Race: African American
Latino
Caucasian
Asian/Pacific Island
Biracial
Other
Marital
Status:
Married
Divorced
Separated
Single
Widowed
Head of Household Family Size: (Include head of Household) Yes No Number of Adults:
Number of Children:
Total Family Size:
Ages of Children:
Reason(s) applicant is in need of emergency assistance: Emergency Assistance Needed For: Temporary job loss Building closing Rent (overdue) Health related interruption of income Eviction/foreclosure First month’s rent to acquire permanent housing Family unification/stabilization Interruption of food stamps Mortgage (overdue) Interruption of income Depleted food stamps Utility (electric, gas, water, sewer) - overdue Disaster Other other (specify)
Last/Current Employer (if applicable):
Name:
Address:
Supervisor:
Income:
Job Title:
Phone:
Monthly Income Monthly Expenses
Source Amount Creditor Amount
TANF Rent
Soc. Sec./SSI/SSDI Mortgage
Employment Gas
Unemployment Electric
Retirement Water
Child Support Food
Food Stamps Other
Other
TOTAL TOTAL
The Salvation Army- National Capital
Area Command
Emergency Assistance Application
FY2022
Page 2 of 5
I. Case Manager’s Summary (this section should include information on the applicant’s current situation/need such as reason for application, type of assistance requested, cause of the hardship, current income support, total amount owed, and financial plan to pay total delinquency including breakdown of which other parties may be contributing and how much): II. Client’s Future Role – (this section should include how the applicant plans to meet future rent/mortgage/utility obligations which may include plans like moving to a lower cost living arrangement, applying for daycare assistance, applying for child support, obtaining additional employment or other sources of income, developing a savings plan, etc.): The Salvation Army- National Capital Area
Command
Emergency Assistance Application FY 2022
Applicant Name
Page 3 of 5
III. Documentation of Extraordinary Circumstances (if applicable) – (this section should include information necessary to justify additional assistance of more than $500.00 including documentation of the extraordinary circumstance):
The Salvation Army- National Capital
Area Command
Emergency Assistance Application
FY2022
Applicant Name
Only to be completed in the event of recommendation for additional assistance: Recommended by: Staff Signature and Title Date
Reviewed by: Corps Officer Signature Date
Final Determination: Additional Assistance Approved and Amount Approved $
Additional Assistance Denied
Page 4 of 5
FINANCIAL NEED(S) OF APPLICANT
Monthly rental/mortgage expense Monthly utility expense Total amount delinquent Total contribution by applicant and/or other sources TOTAL AMOUNT REQUESTED LANDLORD/LENDER/INFORMATION
Name: Account #
Address:
Contact Person: Phone Number:
UTILITY INFORMATION
Vendor: Account #
Address:
Contact Person: Phone Number:
OTHER SERVICE NEEDED (food, clothing, furniture, burial) CIRCLE ONE VENDOR: CONTACT PERSON: ADDRESS: PHONE NUMBER: All information provided in this application is true and correct to the best of my knowledge. I understand that “false statements of information” could render my application invalid for funding consideration. I also understand that completion of this application does not guarantee the granting of funds. Also, by my signature below, I authorize The Salvation Army to gather any necessary information from additional agencies, vendors, or individuals involved in my case in order to qualify me for these funds. This consent will expire one year from the date below unless I indicate the withdrawal of my consent prior to one year signature and in writing to The Salvation Army.
Signature of Applicant Date
Signature of The Salvation Army Staff Date
The Salvation Army- National Capital Area
Command
Emergency Assistance Application
FY 2022
Applicant Name
CHECKLIST Page 5 of 5
Please review to ensure that the file is complete: I. Intake Application
II. Required Documentation
A. General
1. Picture ID/Proof of Residency
2. Proof of Household Income
3. Proof of Household Expenses
B. Assistance Specific
1. Rent
A. Letter from Landlord
1. If landlord letter, it must be on the landlord’s letterhead or Salvation Army letterhead if using verification letter;
B. Letter must include
1. Current monthly rental amount;
2. Due date for monthly rent;
3. Month(s) that is overdue and breakout of other fees (late charges, court costs, etc.) if applicable.
C. Copy of current lease
1. Lease must be in the applicant’s name;
2. Lease must show current monthly rent
3. Lease must show due date of monthly rent.
2. Mortgage
A. Mortgage statement or coupon showing monthly amount due; B. Statement or coupon shows mortgage payment is past due; C. Mortgage must be applicant’s name.
3. First Month’s Rent
A. Copy of lease to include monthly rental amount
B. First month rent verification form
C. Lease must be in applicant’s name
D. Referral letter from shelter or transitional housing program showing current residency in Program;
4. Utility
A. Monthly bill showing delinquency or disconnection notice; B. Utility must be in applicant’s name.
III. Payment
A. If approved, Salvation Army check for no more than $500.00/$750.00 made out to vendor only
(landlord, Mortgage Company, or utility).
B. W-9 form completed for new vendors.
IV. Follow-Up/Outcomes Tracking
A. Completion of 30/60/90 Follow Up (to be completed 30/60/90 days after assistance was approved). V. Other Considerations
A. All bills/lease/mortgage statement in applicant’s name. B. Assistance must ensure that residency or utility service will continue for the next 30 days. C. Proof that outstanding rent/mortgage/utility balance paid (copies of other agencies’ confirmation letter, copies of money orders, copies of other agencies’ checks, etc.). D. Strongly recommend use of Salvation Army verification letters.
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