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Full Name: L L )UL
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CRF HOUSING ASSISTANCE INTAKE APPLICATION 1. TYPE OF HOUSING ASSISTANCE What type of housing assistance are you Circle all,that apply Other (Explain) 2. TO BE COMPLETED Full Name: )UL Current Address: i / I - • City, State Zip: 'it Daytime phone: /^ ^M- E-mail Address: ^^\il-t; '.:•>- Marital Status: ^\ l\i!.:-r /;', Hfc^r Currently Employed? 3. TO BE COMPLETED Full Name: '•i ' ' ; • Daytime phone: ; /, ^ E-mail Address: i '. ., • Marital Status: /y* /y/ Currently Employed? REQUESTED requesting? ^ Rent ./ BY APPLICANT: (Head of Household) .:) ^ t i 'i! .. / 3-';' ; »." i I ^.- .-. r.. • -^^ 3- . '-i ^;_j1'll<'^ l^-r Yes [ L_L .' ,. . . ;!-• -, ' .i\r':^ "' '^ . I - •' •''—-- _-^>^J • ?./. •"'-;'! / ! f . • .'.o^. No Mobile Phone: Date of Birth: ± A8e: :; <, < t- Self Employed? BY CO-APPLICANT ( ADDITIONAL SHEETS IF i i! J^-.; ^ 11/. J J,J- ; *i^al"cj' '•^.'td;; Yes /1 J; ^ ^,1} i s . C/ ^- No Mobile Phone: Date of Birth: .; A9e: J I: i T-1 Self Employed? Mortgage .>i\H1^ -' ,A-i / /; <' Yes ; No NECESSARY) )l<^ •'.hh:./ Yes No Page 11 SAMPLE
Transcript of Full Name: L L )UL
CRF HOUSING ASSISTANCE INTAKE APPLICATION
1. TYPE OF HOUSING ASSISTANCE
What type of housing assistance are you
Circle all,that applyOther (Explain)
2. TO BE COMPLETED
Full Name:
)ULCurrent Address:
i /I - •
City, State Zip:'it
Daytime phone: /^^M-
E-mail Address:^^\il-t; '.:•>-
Marital Status:^\ l\i!.:-r/;', Hfc^r
Currently Employed?
3. TO BE COMPLETED
Full Name:'•i
' ' ; •
Daytime phone: ; /, ^
E-mail Address: i '. ., •
Marital Status: /y* /y/
Currently Employed?
REQUESTED
requesting?
^ Rent ./
BY APPLICANT: (Head of Household)
.:) ^ t i 'i!
.. /
3-';' ; »."i I ^.-
.-. r..
• -^^ 3- .
'-i ^;_j1'll<'^
l^-r
Yes
[L_L
.' ,. . . ;!-• -,
' .i\r':^ "' '^ . I- •' •''—-- _-^>^J •
?./. •"'-;'!
/ ! f
. • .'.o^.
No
Mobile Phone:
Date of Birth:
±A8e: :; <,
< t-
Self Employed?
BY CO-APPLICANT ( ADDITIONAL SHEETS IF
i i!J^-.; ^ 11/.
J J,J- ;
*i^al"cj'
'•^.'td;;
Yes /1
J; ^
^,1} i s . C/ ^-
No
Mobile Phone:
Date of Birth:.;
A9e: J I: iT-1
Self Employed?
Mortgage
.>i\H1^
-' ,A-i / /;<'
Yes ; No
NECESSARY)
)l<^
•'.hh:./
Yes No
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4. HOUSEHOLD COMPOSITION. CHARACTERISTICS AND FAMILIAL STATUS: - As of today, all other^nembers"of the household. Indicate the relationship of each family member to the Head of Household (spouse, sibling, etc.). Inaddition, indicate if there are any additional members in the near future to the household. Add a separate sheet if youneed more space.
HouseholdMember Name
Relationship toHead of
HouseholdAge
Date ofBirth
MaritalStatus
Is householdmember listed
disabled?Y/N
Currently Employed
1-TTiM s^im .^n /J [°L H/(5-//0d 5i(s)^t.£ (^ JM. No
LftJiz^ JM'ffU t^^t+Tb^ _^L 3 ft0 (Q(s oi'^b'ii-G N Yes No~''
Yes No
Yes No
Yes No
Yes No
5. RACE AND ETHNICITY FOR HEAD of HOUSEHOLD (Check one): -This information is being collected for reportingpurposes only.
RACE (Check all that apply):
D American Indian or Alaska Native D Asian
D Native Hawaiian or Other Pacific Islander D White
D Black or African American B^ Other Multi-Racial
ETHNICITY (Check one):
D Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanishculture or origin, regardless of race. The term, "Spanish origin," can be used in addition to "Hispanic or Latino."
D Non-Hispanic or Latino - A person not of Cuban, Mexican, Puerto Rican, South or Central American, or otherSpanish culture or origin, regardless of race.
6. ELIGIBILITY/COVID-19 INFORMATION:If the answer to any of the following questions is NO, you are not eligible for assistance:
Were you or a household member financially affected by the COVID-19 due to loss of job; reduced hours; furlough?
Q'VES D NO
How many household members were financially affected by COVID-19?
For each Household member financially affected by COVID-19, provide the following information:
1st household member financially affected by COVID-19
Name:'/'.•,; »-^-
Are they unemployed or underemployed (reduced hours; had totake a job making less money) due to COVID-19?
l^fYES D NO
Date person became unemployed orunderemployed nj
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What was the annual gross income (this is before taxes are taken out; NOT your take home pay) of this person prior tobeing affected by COVID-19 or March 1, 2020 whichever is later? ^- , ' .
Current employer (as of the day you are completing the application): ..., ^ '"FH^ 0 £-)-!' (ter^L
What was the projected annual gross income (this is before taxes are taken out; NOT your take home pay) of thishousehold after being affected by COVID-19? ^ 7^i5 0 0^-
Is the person receiving unemployment benefits? Yes or fN^'
If yes, how much are they receiving monthly $
Provide additional information about Hardship:
"i'^-E- \'3e^v \{o^: ^?0^^ ^y Ht)i)^ ^€l/t/; ^)f"
^.CiC t/J?(- •^) ^0+-j)^-^^^'Oc;£'T7) L/VG'^
6;r; /?)0o^-! ^^e' ^^ Ap^i^ -
2nd household member financially affected by COVID-19 (if applicable) ADD ADDITIONAL SHEETS IF NEEDED
Name: ,^
"0 A i I?.7-Are they unemployed or underemployed (reduced hours; had to take ajob making less money) due to COVID-19?
Date the person became unemployed or underemployed (reducedhours; had to take a job making less money)
Q^ES D NO
5'-l-Zo
What was the annual gross income of this person prior to being affected by COVID-19 or March 1, 2020 whichever islater? ^f~'/ .:.,'(;/,':• i'
Current employer (as of the day you are completing the application):
N U<^
What was the projected annual gross income (this is before taxes are taken out; NOT your take home pay) of thishousehold after being affected by COVID-19? (<j ^ ^ ^
Is the person receiving unemployment benefits? Yes or /No
If yes, how much are they receiving monthly $
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Provide additional information about Hardship:
X ^'A:-- IAIJ^ 0-1-F1 -fc'/'4 At y [ot. (Jj4k
AO/Z L.^J^Cm)i(OCn DL)^ "^ !nch ^i-^oeK.
7. PROPERTV INFORMATION
Do you rent or own a mobile or manufactured home? DYES NO
Are you past due or delinquent on your rent or mortgage? EfYES a NO
What is your monthly rent payment? Monthly Payment,,$ l^f)p<?y
How many months pf rent are past due?
^Total Amount Due as ofjtje date of the application:$ P5'r%t5'00> ^dL}D,—. IA-^ ^/A^t?S>
What are the late charges due, if any?
^'/./',,. fl" ^ •'' ,•' /'•'I' C€. 5 /v!C'/l4-L-b ::'- ^'^;
ec
Landlord's Name and Mailing Address of where rent payment is to be mailed:
.-jn^.-> ?^l. ^:)(^r^ c2t-.
o'r'o -StL^-e^ ^ I 2^4
\u^es , ^ ^'U:^}"]Landlord's Contact Phone Number:
^OLf- :S'?S- b^^-\1
Landlord's Email Address:
i.::^f-JO^c:^-^ \>: '.Uti , Cj'i /'/
What is your monthly mortgage payment?^ /r3-
How many mortgage payments are past due? Total Amount Dqe:$ ^'1^f.- I <^
What are the late charges due, if any?
1^1 ^\ -
Mortgage Company Name and Mailing Address of where mortgage payment is to be mailed:;
/.i n •
Mortgage Company Contact Phone Number:
(• i '".
Mortgage Company Email Address:
,'L./1-' :1 K
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8. OTHER ASSISTANCE
The following question will require a special review to determine eligibility:
Did you apply for COVID-19 assistance to any other program or organization? Ifyes
E3'"YES D NO
Explain:^lc^Al^s. pA(Z- CU.^ fe'^(L-i'^'C ^,'11 ^.1 6^1'/fc^/i L't-T^
ft q ^ •
Have you received any COVID related assistance? D Yes 0<oAmount Approved? Amount Received to date:
List agency providing services
9. INCOME INFORMATION: Income includes: Wages, salaries and tips, alimony, child support, military income, part-time income, temporary income, TANF, Social Security, unemployment benefits, other benefits for all householdmembers. List ALL household members and their incomes. Attach a separate sheet if you need more space.
FOOD STAMPS ARE NOT CONSIDERED INCOME- do not list food stamps.
Household Member NameFull TimeStudent?
Y/N
Source of Income(include employer name)
If Applicable
Rateof Pay
Payment Basis(hourly, weekly,monthly, etc.)
.^Xtfc. ^)MivH- ^ 'H-e K(?^T' I^T^L. ^l^i n'-',A.(t^\,
^C.tf ^MiTlr ^ -^L3/A/^t^Al^T
^A.^iy/tft^
MA.'}r:C\ •Q^irir M \^Jt,^.d
^J !/>• •Ll^H-. O^iV t. i j)" ^/ri
11. ASSET INFORMATION: Provide the requested information on any assets you may have.
Do you own any other real estate (other than your home you live in)? D Yes O^Jo D N/AIf yes, provide address, city and state ofproperty(s):
^ !^What is the current tax roll value of the property (contact County Property Appraiser orincluded on last property tax bill)?
$ M'^If mortgaged, what is the current balance owed on the mortgage (contact mortgage company)?
t^l^Do you have rental income from the property? D Yes D No
If you answered yes, provide amount of annual rental incomef
Is your primary residence currently in foreclosure? D Yes D No
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12. ELIGIBILITY RELEASE: It issponsor, State or Vendor to requestprogram.
equired that you sign this application form, which allows Nassau County, subrecipient,est information from Third Parties concerning your eligibility and participation in this
Information Covered: Inquiries may be made about items initialed below by the applicant.
Instructions to Applicant: Your signature on this application form, and the signatures of each member of yourhousehold who is 18 years of age or older, authorizes Nassau County or any of its duly authorizedrepresentatives to obtain information from a third party regarding your eligibility and continued participation inthe CRF Program for disaster assistance. Each member of the household who is 18 years of age or older,must sign this application form,
Information provided by the applicants) may be subject to Chapter 119, Florida Statutes, regarding OpenRecords.
List below the types and sources of any household assets (checking accounts, savings accounts, 401 K, CDs, retirementaccounts stocks). Provide both the current cash value and the estimated annual income from the asset. Provide thisinformation for all household members.
Household Member Name
OU-E +-^o5 "^M\r^
~\)^t<- -h^ 5hi^ri-
<^' ^AU r^
Type & Source of Asset
f\^c^^^WJ^OT^/L^ihi^
13. APPLICANT CERTIFICATION:Certify that all the information in the application is true,application to verify the information contained, the applicantauthorized representatives to verify the information listed herein.
Cash Value of Asset
^?50^-
^ 6°'"
^^.
3 the best of your krit authorizes Nassauein.
Annual Income fromAsset
^-i-
M-
)wledge. By signing thisbounty or any of its duly
1/We understand the information provided above is collected to determine if 1/we are eligible to receive assistance underthe CRF program.1/We hereby certify that all the information provided herein is true and correct.1/We understand that providing false statements or information for the purpose of obtaining assistance is grounds fortermination of housing assistance and is punishable under Chapter 817 of the Florida Statutes as a first-degreemisdemeanor.
1/We authorize the above-referenced County/subrecipient/sponsor and any of its duly authorized representatives to verifyall information provided in this application.1/We understand that additional information will likely be required to move forward with this program.
Applicant's Authorization:I authorize the above-named Subrecipient, Sponsor, State or Vendor to obtain information about me and my householdthat is pertinent to determining my eligibility for participation in the Program. I acknowledge that:(1) A photocopy of this form is as valid as the original; AND
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(2) I have the right to review information received using this form; AND(3) I have the right to a copy of information provided to the Subrecipient and to request correction of any information I
believe to be inaccurate; AND(4) All adult household members will sign this form and cooperate with the Subrecipient in the eligibility verification
process.
(5) Applicants who provide a self-certification will be required to provide proof of income when the President's orGovernor's executive order expires. If the applicant falsified information to obtain assistance, all funds paid on behalfof the applicant must be repaid to the program.
Signature of Applicant: /TA-^l ( )/V^^f^y^J'-- -~ ) f '-^ ^s^ .^7 •-
Signature of Co-Applicant; ^ /.<^ ' '"'a°°) ^f^-^''- '
Household member ^ ^18 years or older: V/.^ . -°:S^i-/-A^
Household member18 years or older:Household member18 years or older:Household member18 years or older:Household member18 years or older:
Date H-^Q-^0
Date /7-^-^
Date /y/^'' :1^€-'7T
Date
Date
Date
Date
Warning: Chapter 817 of the Florida Statutes provides that willful false statements or misrepresentation concerning incomeand assets or liabilities relating to financial condition is a misdemeanor of the first degree and is punishable by fines andimprisonment provided under §775.082 or 775.083.
FOR OFFICE USE ONLY
Application Number:
Application Received By: Date Application Received:
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