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People Trust EMERGENCY SOLUTIONS GRANTS (ESG) PROGRAM
5300 West 65th Street, Little Rock, AR 72209
501-404-4857 (phone) 501-476-3910 (fax)
The People Trust ESG Program is a grant funded program dedicated to providing assistance to individuals or families within the community who are at risk of being homeless or literally homeless as defined by the
Department of Housing and Urban Development under the Hearth Act
HOMELESS DETERMINATION
Literally Homeless-An individual or family who lack a stable, regular and nighttime residence, meaning the individual or family has a primary nighttime residence that is a public or private place not mean for human habitation or is living in a publicly or privately operated shelter designed to provide temporary living arrangements. This category also includes individuals who are exiting an institution where he or she resided for 90 days or less who resided in an emergency shelter or place not meant for human habitation immediately prior to entry into the institution.
At Risk of Homelessness-An individual or family who will lose (within 14 days) their primary nighttime residence provided that no alternative residence has been identified and the individual or family lacks the resources or support networks needed to obtain other permanent housing.
Other-Unaccompanied youth (under 25) or families with children and youth who do not otherwise qualify as homeless under this definition and are defined as homeless under another federal guideline, have not had permanent housing during the past 60 days, have experienced constant instability, and can be expected to continue for an extended period of time.
Fleeing/ Attempting to flee a domestic violence situation.
At Risk of Homelessness
Please provide at least one of the following:
□ A court order or documentation of an eviction action notifying the individual or family thatthey must leave
□ A documented shelter statement or oral statement of homelessness□ Self-Report, or other written documentation that the individual or family lacks the financial
resources and support networks to obtain other permanent housing.□ Oral statement by the individual or head of household is seeking assistance due to fleeing a
domestic violence situation.
Client Signature ____________________ Date ____ _
People Trust EMERGENCY SOLUTIONS GRANTS (ESG) PROGRAM
5300 West 65th Street, Little Rock, AR 72209
501-404-4857 (phone) 501-476-3910 (fax)
The ESG program provides temporary financial assistance and stabilization services to individuals and families who are homeless or at risk of being homeless. Our goal is to prevent future housing instability by linking our participants with community resources and mainstream benefits that will help empower them as they work towards a plan for future housing stability.
There are two cate_gories for assistance: Homeless Prevention Assistance: For individuals and families who are currently housed but are facing eviction or who may be at risk of becoming homeless. This temporary stabilization assistance will prevent the individual or family from moving to an emergency shelter, or a place not meant for human living.
Rapid Re-Housing Assistance: For individuals or families who are living in emergency shelters or in a place not meant for human living. Temporary assistance can be provided so they can find affordable permanent housing and movie into as quickly as possible.
What is required to receive assistance? ► Complete an intake assessment► Must be certified as homeless or at risk of being homeless► The family or participants must lack the resources or family networks to secure or maintain
permanent housing on their own► Participants must provide documentation verifying the need for assistance ( eviction notice,
lease, verification of homelessness)► Must establish and commit to following a housing stability plan► Must not be receiving rental assistance from another HUD funded program► Rent must be reasonable, at or below fair market rent limit► Housing must pass inspection
Failure to comply with program requirements may result in termination from the program.
T)!pe a/Assistance Depending on each participant's individual needs, rental assistance may be provided as follows:
► Short-term► Medium-term► Rental arrears► Utilities payments ( deposits, past due utility bills)
Based on your assessed needs your assistance will be ___ short term ___ medium term
***Past due rent and utilities may not exceed 6 months ***
HPRP assistance is not intended to provide long-term support for program participants, nor will it be able to address all the financial and supportive services needs of households that affect housing stability.
Client Signature ______________________ Date _____ _
� People Trust
EMERGENCY SOLUTIONS GRANTS (ESG) PROGRAM
5300 West 65th Street, Little Rock, AR 72209
501-404-4857 (phone) 501-476-3910 (fax)
CATCH Coordinated Entry Form
ESG Project: ___ Homelessness Prevention: ___ Rapid Re-Housing: ______ _ Screened by: Agency: Date of Screening: ____ _
Participant Information Name: ___________________ .D08: ______________ _
Address: __________________ Gender: _____________ _
City:, ____________ State: ___ Zip: ________________ _
Phone: _______ Email: _________________________ _
Prioritized Vulnerability Criteria
Chronically Homeless: __ Homeless > 12 Months __ Homeless at least 4x in the last 3 years
Veteran Status: __ Honorable __ Dishonorable __ N / A
Household Members: Adults __________ Children __________ _
*If client is identified to be a vulnerable population, please contact designated agency.For all Families and chronically homeless individuals contact:
River City Ministry at 501-978-0102 or LRCMHC at 501-686-9300
Person Contacted:_________ Date/Time: ______________ _ For Veteran Services contact:
CAVHS at 501-244-1900 or St Francis House (SSVF) at 501-916-2514
Person Contacted: __________ Date/Time: _______________ _
Where did the client/family sleep last night? _Shelter _Friend/Family's_ Streets/Car _Rental Unit_Owns Home __ Other
Services Needed (Circle all that apply): Emergency Shelter Employment Substance Abuse Treatment Disability Benefits
Domestic Violence Mental Health Medical Housing and/or Rental Assistance Transportation Birth Certificate and/or ID
Referrals Out Agency Name: _____________________ Phone: ______ _ Person Contacted: Date/Time: _____ _ Agency Name: Phone: ______ _ Person Contacted: Date/Time: ____ _ Agency Name: Phone: ______ _ Person Contacted: Date/Time: ____ _
I/We, ___________ ___, authorize the staff of the People Trust to exchanges orrelease information to agencies within the Central AR Continum of Care for the purpose of assisting with maintaining or obtaining housing for myself/my family.
Signature: _____________________ Date: _________ _
People Trust EMERGENCY SOLUTIONS GRANTS (ESG) PROGRAM
5300 West 65th Street, Little Rock, AR 72209
501-404-4857 (phone) 501-476-3910 (fax)
AFFIDAVIT OF INCOME/HOUSEHOLD COMPOSITION /ELIGIBILITY
Print Name: ____________ Date: ___________ _
Phone: _________ Email: _______________ _
STATEMENT OF CURRENT INCOME: You must provide a detailed report of all
income, and any changes which have occurred, within your household. Any
incomplete or vague answers may delay the processing of your file, so please be as
specific as possible. (Example: What the income source is, how much the rate of pay
is, how many hours worked a week.)
If this is a CHANGE provide the date change occurred. _________ _
Type of Change: Income ___ .Household Composition. ___ Other ___ _
I, ______________ do hereby state under oath the above
information is true and correct to the best of my knowledge.
State of Arkansas}
) ss
County of Pulaski}
Signature of Applicant/Tenant
SUBSCRIBED AND SWORN to before me on this the ___ day of __ --6 __ _
Signature of Notary
My Commission Expires: ______ WARNING 18USC provides, among other things, that whoever willingly makes or used a document or writing continuing any false, fictitious, or fraudulent statement or entry within the Jurisdiction of any department or agency of the United States shall he fined not more than $10,000 or imprisoned for not more than five(S) years , or both.
.. People Trust
EMERGENCY SOLUTIONS GRANTS (ESG) PROGRAM
5300 West 65th Street, Little Rock, AR 72209
501-404-4857 (phone) 501-476-3910 (fax)
APPLICATION FOR TENANT ELGIBILITY NAME: _________________________________ _ ADDRESS: ________________________________ _ CITY,STATE,ZIP: ______________________________ _ PHONE NUMBER: ______________________________ _ EMAIL ADDRESS: ______________________________ _
SIGNATURE OF APPLICANT /TENANT DATE
Household Composition: List each family member. Identify full-time students over 18. # Name Relationship Sex DOB Place of Birth SS#
1.
2.
3.
4.
5.
6.
7.
8.
Income: Includes Employment, AFDC(TEA), Child Support, SS, SSI, Pension and Household Composition: Unemployment
# Source, Rate and Type Annual Aged 62 or Older #
Disabled/Handicapped #
None of the Above #
Applicant/Tenant Nationality:
Assets: Includes automobile, stock, bonds, IRA
# Description Annual 1. White2. Black or African American3. American Indian or Alaska Native4. Asian5. Native Hawaiian Or Other Pacific Islander
Allowances: 6. Mixed Race7. Hispanic
# Description Annual 8. Other
DO NOT WRITE BELOW THIS LINE-FOR HOUSING PERSONNEL USE ONLY Original Application: ________________ Tenant Number: ________ _ Application Number: _______________ Voucher Number: ________ _
Authorization for the Release of Information/ Privacy Act Notice to the U.S. Department of Housing and Urban Development {HUD) and the Housing Agency/Authority {HA)
U.S. Department of Housing and Urban Development Office of Public and Indian Housing
0MB CONTROL NUMBER: 2501-0014
exp. 1/31/2014
PHA requesting release of information; (Cross out space If none) (Full address, name of contact person, and date)
IHA requesting release of information: (Cross out space If none) (Full address, name of contact person, and date)
Authority: Section 904 of the Stewart B. McKinney Homeless Assistance Amendments Act of 1988 , as amended by Section 903 of the Housing and Community Development Act of 199 2 and Section 3003 of the Omnibus Budget Reconciliation Act of 199 3. This law is found at 42 U .S.C. 3544.
This law requires that you sign a consent form authorizing: ( 1 ) HUD and the Housing Agency/Authority (HA) to request verification of salary and wages from current or previous employers; (2) HUD and the HA to request wage and unemployment compensation claim information from the state agency responsible for keeping that information; (3) HUD to request certain tax return information from the U.S. Social Security Administration and the U.S. Internal Revenue Service. The law also requires independent verification of income information. Therefore, HUD or the HA may request information from financial institutions to verify your eligibility and level of benefits.
Purpose: In signing this consent form, you are authorizing HUD and the above-named HA to request income information from the sources listed on the form. HUD and the HA need this information to verify your household's income, in order to ensure that you are eligible for assisted housing benefits and that these benefits are set at the correct level. HUD and the HA may participate in computer matching programs with these sources in order to verify your eligibility and level of benefits.
Uses oflnformation to be Obtained: HUD is required to protect the income information it obtains in accordance with the Privacy Act of 19 74, 5 U.S.C. 552a. HUD may disclose information ( other than tax return information) for certain routine uses, such as to other government agencies for law enforcement purposes, to Federal agencies for employment suitability purposes and to HAs for the purpose of determining housing assistance. The HA is also required to protect the income information it obtains in accordance with any applicable State privacy law. HUD and HA employees may be subject to penalties for unauthorized disclosures or improper uses of the income information that is obtained based on the consent form. Private owners may not request or receive information authorized by this form.
Who Must Sign the Consent Form: Each member of your
household who is 18 years of age or older must sign the consent form. Additional signatures must be obtained from new adult members joining the household or whenever members of the household become 18 years of age.
Persons who apply for or receive assistance under the following programs are required to sign this consent form:
PHA-owned rental public housing
Turnkey III Homeownership Opportunities
Mutual Help Homeownership Opportunity
Section 23 and 19 ( c) leased housing
Section 23 Housing Assistance Payments
HA-owned rental Indian housing
Section 8 Rental Certificate
Section 8 Rental Voucher
Section 8 Moderate Rehabilitation
Failure to Sign Consent Form: Your failure to sign the consent form may result in the denial of eligibility or termination of assisted housing benefits, or both. Denial of eligibility or termination of benefits is subject to the HA 's grievance procedures and Section 8 informal hearing procedures.
Sources of Information To Be Obtained
State Wage Information Collection Agencies. (This consent is limited to wages and unemployment compensation I have received during period(s) within the last 5 years when I have received assisted housing benefits.)
U.S. Social Security Administration (HUD only) (This consent is limited to the wage and self employment information and payments of retirement income as referenced at Section 6103(1)(7)(A) of the Internal Revenue Code.)
U.S. Internal Revenue Service (HUD only) (This consent is limited to unearned income [i.e., interest and dividends].)
Information may also be obtained directly from: (a) current and former employers concerning salary and wages and (b) financial institutions concerning unearned income (i.e., interest and dividends). I understand that income information obtained from these sources will be used to verify information that I provide in determining el igibi I ity for assisted housing programs and the level of benefits. Therefore, this consent form only authorizes release directly from employers and financial institutions of information regarding any period(s) within the last 5 years when I have received assisted housing benefits.
Original is retained by the requesting organization. ref. Handbooks 7420.7, 7420.8, & 7465.1 form HUD-9886 (7/94)
� People Trust
EMERGENCY SOLUTIONS GRANTS (ESG) PROGRAM
5300 West 65th Street, Little Rock, AR 72209
501-404-4857 (phone) 501-476-3910 (fax)
My Signature Below Certifies That:
1. I have read and understand that I have been given a copy of the "The Truth About Lead PaintPoisoning" flier. I have been advised that if the dwelling unit I choose was built before 1978,it may contain lead-based paint.
2. I have read and understand the Federal Privacy Act Statement.3. The information given to People Trust on household composition, income, net family assets,
allowances and deductions is accurate and complete to the best of my knowledge and belief.I understand that false statements or information are punishable under Federal Law, and thatif I knowingly falsify or omit information, I may be:
a. Evicted from my unit.b. Required to repay overpaid assistance my family received.c. Fined up to $10,000.00.d. Imprisoned for up to five (5) years; and/ore. Prohibited from receiving future assistance
After Verification by the People Trust, the information may be submitted to the Department of Housi-ng and Urban Development on Form HUD-50058, Tenant Data Summary, a computer generated a facsimile of the form, or a magnetic media. See the Federal Privacy Act Statement for more information about the use of this data.
4. The Social Security/ Alien Registration Numbers that have been provided to the People Trustis complete and accurate and has been assigned to the person indicated, and I have provideddocumentation of such numbers for the persons in my family.
Print Name Address
Signature of Head of Household City, State & ZIP
Signature of Spouse or Other Adult Date
If you believe you have been discriminated against, you may call the Fair Housing and Equal Opportunity National toll-free hotline number at 1-800-669-9777. For the hearing impaired, the toll-free number for use with TDD equipment is 1-800-927-9275.
