Working Copy Clone of 2023 Community Services Application

2024 Community Services Application

PLEASE NOTE: Incomplete applications will not be processed!
- Applications will be accepted by email, fax, mail, or drop off and will be processed according to priority and date received.
- Please note it can take anywhere from 6 to 8 weeks to process complete applications and in some cases may take longer depending on the time of the year and the number of applications already in process.
- You are still responsible to pay your bill until your application is processed and you are notified of outcome.
- This application is for screening purposes only and does not guarantee your eligibility to receive services.
All assistance is subject to the availability of funds.
REQUIRED DOCUMENTS FOR ALL PROGRAMS
- Completed application including all required documents.
- Social security cards for all household members
- Proof of ALL income FOR THE PAST 30 DAYS for every household member 18 years or older, who works or receives assistance. (Check stubs, Social Security/SSI, award letters including minor children receiving any type of SS benefit included) Letters must be from Social Security Administration and must reference or be dated for the current year, VA letter, unemployment, TANF letter, SNAP letter, retirement, pension, child support, etc.
  Bank statements and tax returns are not acceptable.
- If any household member 18 or over is NOT receiving any income, you must complete the attached Declaration of Income Statement.
ELECTRIC, GAS & WATER ASSISTANCE, REQUIRES ALL ABOVE DOCUMENTS AND THE FOLLOWING
- Proof of Citizenship for ALL household members. (Certified Birth Certificate or US Passport) NO EXCEPTIONS!
- Photo ID for all household members 18 and older (Drivers License, State ID, School ID, Military ID)A 12 month billing history from each of your energy providers (ELECTRIC, WATER, NATURAL GAS AND/OR PROPANE) NOTE: if you have lived less than 12 months in your home, provide history for as many months as possible.1
- Your current and past due bills for electric and a disconnect notice if applicable.
  Your current and past due water/wastewater bill and a disconnect notice if applicable.
INCOMPLETE APPLICATIONS CANNOT BE PROCESSED.
Best way to contact us:
Email to: utilityassistance@communityaction.com
Fax : 512-392-4255
Phone : 512-392-1161
Upload required supporting documentation here*

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CONFLICT OF INTEREST INFORMATION

	Yes	No	Identify who and role
Is anyone in the household currently serving as an employee, agent, consultant, and officer or elected or appointed official of Community Action, Inc. of Central Texas? If YES Identify who and what role.
Is anyone in the household related to anyone currently serving as an employee, agent, consultant, officer or elected official of Community Action, Inc. of Central Texas? If YES, identify who and what role.

FOR OFFICE USE ONLY: If there is a Conflict of Interest, this application requires the Executive Director's Signature.
Executive Director Signature ________________________________________________________

OFFICE USE ONLY: CEAP/ LIHWAP/ CSBG ELIGIBILITY DETERMINATION

Calculations: Monthly            x12 =

                Monthly            x12 =           Total Annual Income $

Household Poverty Income Level:         0-50%    >50-75%         >75-125%         >125-150%    >150-200%

Verification/Documentation of Household Income used:

Staff Signature    Date
OFFICE USE ONLY: Client potentially eligible for the following Community, Inc. programs and referrals:

___ Head Start/Early Head Start ____Health Services ____Adult Education ____ Community Services
___ CEAP ____ LHWAP ____CSBG ____Senior Citizen Center ____ Lifeline ____SMEU
AUTHORIZATIONS AND RELEASE OF INFORMATION:

1. The information provided is true and correct to the best of my knowledge and belief.
2. I understand that my gross household income is annualized at the time of application according to pre-established agency rules and procedures in order to receive assistance.
3. I understand that I may request a hearing to appeal a denial of eligibility, amount of assistance received, or a delay in receiving services from Community Action, Inc. of Central Texas.
4. I authorize the Texas Department of Housing and Community Action, Inc. of Central Texas to solicit/verify information including employment verification needed to provide assistance with my utilities and/ or fuel bills, both past and future.
5. I am an applicant of Community Action, Inc. of Central Texas. I hereby give my permission to release and verify all information requested and understand that it will be kept in strict confidence to be used for program purposes only.I understand that photocopy of this release is as valid as the original and may be used to obtain employment information or verify other data.
6. I understand that if I change utility companies I must notify the case worker within 10 business days of my new utility company and account number with the name on the account. If I do not notify Community Action, Inc. of Central Texas of my new utility company, I will lose any payments due. When the information is provided, any remaining assistance may be reinstated.
7. If I or another member of the household has no income the Declaration of No Income sheet must be completed for all household members over 18 years of age having no income. Note: On this sheet do not include anyone who has shown income on the application. The Declaration of No Income no longer needs to be notarized.
8. I UNDERSTAND THAT I AM SUBJECT TO PROSECUTION FOR PROVIDING FALSE OR FRAUDULENT INFORMATION ON THIS APPLICATION. In addition, I understand that I may be terminated from receiving services if I display threatening
behavior, sexual harassment, verbal abuse, theft, or violation of Community Action, Inc. of Central Texas firearm
policy. I understand if terminated, I will not be able to reapply for 2 years.
9. I designate Community Action, Inc. of Central Texas to release and discuss information
To:
Relationship:
Contact Info:
By signing below,I acknowledge that I have read, understand and agree with the entire CAICT application:

I certify that the information on this application is correct and I also understand that receipt or assistance through
misrepresentation or fraud is punishable by fine or imprisonment.
Applicant Signature*

Clear
Date*

MonthDayYear
Staff Signature
(when application is logged in)

Date:

TEXAS DEPARTMENT OF HOUSING AND COMMUNITY AFFAIRS

Systematic Alien Verification for Entitlements (SAVE) System and US Citizenship/US National Applicant Certification Form for CEAP

The program for which you are applying requires verification that you are a U.S. citizen, a non‐citizen national, or a legal resident of the United States. Documentation of your status is required. This agency uses the Systematic Alien Verification for Entitlements (SAVE) System to verify the status of non‐citizens.

	Household Member Name	U.S. Citizen (Born or Naturalized) or U.S. National	Qualified Alien	Office Use Only Documentation Provided for Status	Office Use Only Documentaion Provided for Identification
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

To add additional household members, use another copy of this form.
I AM AWARE THAT I AM SUBJECT TO PROSECUTION FOR PROVIDING FALSE OR
FRAUDULENT INFORMATION.
Applicant Signature*

Clear
Date*

MonthDayYear
Signature of agency staff certifying the above Date

Print Staff Name Date

Community Action, Inc. of Central Texas

2024 Intake Application
NEEDS ASSESMENT

Please indicate what OTHER NEEDS you may have below by selecting either YES or NO in each box. If you select YES, please explain the need you are experiencing so that we may help you in locating services in our agency or referrals to partner agencies.

	Need	Explanation
BASIC NEEDS: Food, Clothing, Food Stamps, WIC, Meals On Wheels, Emergency, Other
INCOME: SS, SSI, TANF, VA, Child Support, Budget, Other
EMPLOYMENT: Looking For A Job, Job Search Assistance, Resume, Other
UTILITY ASSISTANCE: Electric, Natural Gas, Propane, Waater, Other
HOUSING: Temporary Shelter, Subsidized, Section 8, Housing, Repairs, Weatherization, Other
HEATING / COOLING Heaters, Window Units, Repairs, Water Heater
CARE NEEDS: Child Care, Elderly Care, Other
COUNSELING: Family, Alcohol/Substance Abuse, Other
TRANSPORTATION: To Work, Dr. Appointment, Car Repair, Other
VETERAN NEEDS: Medical, Training, Home Repairs, Accessibility, Other
LEGAL: Child Support, Criminal Civil. Other
HEALTH: Immunizations, Prescriptions, Primary Health Care, Mental Health, Other
EDUCATION: GED, English as Second Language-ESL, Vocational Training, Other
Other Needs Not Identified On This Assessment:

Declaration of Income Statement
Applicant First Name
Applicant Last Name
Suffix
Address
City
Zip Code
State the gross income for household members, 18 years and older (including students), who have no documentation of the income received in the 30 day period prior to the date of application for assistance:

	Name	Gross Income Received
1
2
3
4

My household has no documented proof of income due to the following situation
I certify that the above information is true and correct to the best of my knowledge and belief.

I understand that the information willl be verfied to the extent possible, and that I may be subject to prosecution
for providing false or fraudulent information.
Signature

Clear
Date

MonthDayYear

Community Action, Inc, of Central Texas
COMMUNITY SERVICES

Self Certification of Disability
Applicant's Name
Name of Person with Disability
Relationship of Person with Disability to Applicant
Persons with Disabilities--Any individual who is:

-A handicapped individual as defined in §7(9) of the Rehabilitation Act of 1973;

-Under a disability as defined in §1614(a)(3)(A) or §223(d)(1) of the SocialSecurity Act or in V102(7) of the Developmental Disabilities Services andFacilities Construction Act: or

-Receiving benefits under 38 U.S.C. Chapter 11 or 15.

APPLICANT’S AUTHORIZATION TO DECLARE DISABLED STATUS:
I hereby confirm my eligibility as a Person with Disability, in accordance with the above-stated definition of Person with Disability.
Signature of Person with Disability or His/Her Guardian

Clear
Date

MonthDayYear
Should be Empty:

Best way to contact us:
Email to: utilityassistance@communityaction.com
Fax : 512-392-4255
Phone : 512-392-1161

Work Status 18 or over

Work Status 18 or over

Work Status 18 or over

Work Status 18 or over

Other Household Members

Work Status 18 or over

Other Household Members

Work Status 18 or over

Other Household Members

Work Status 18 or over

Other Household Members

Work Status 18 or over

Other Household Members

Work Status 18 or over

Other Household Members

Work Status 18 or over

Community Action, Inc. of Central Texas

Declaration of Income Statement

Best way to contact us:Email to: utilityassistance@communityaction.comFax : 512-392-4255Phone : 512-392-1161

Work Status 18 or over

Work Status 18 or over

Work Status 18 or over

Work Status 18 or over

Other Household Members

Work Status 18 or over

Other Household Members

Work Status 18 or over

Other Household Members

Work Status 18 or over

Other Household Members

Work Status 18 or over

Other Household Members

Work Status 18 or over

Other Household Members

Work Status 18 or over

Community Action, Inc. of Central Texas

Declaration of Income Statement

Best way to contact us:
Email to: utilityassistance@communityaction.com
Fax : 512-392-4255
Phone : 512-392-1161