Pasco HEART Application

CCDOSP Service Assistance

Service Application for Pasco H.E.A.R.T.
CCDOSP Service Assistance/general service application
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Note: you must include these items with your application. You can attach them to this application by having them on your computer or taking clear photos with a phone or e-mailing them to your Case Manager later, but no application will be processed without these items:

1. Identification needed:
• Driver’s license for all household members 18 or older
• Birth Certificates, SS cards, shot records, or school ID for all household members under 18.

2. Proof of income needed (include all that apply):
• 2020 Income Tax Return
• Wage Information (Form W-2 and/or 2 months of paystubs)
• Social Security or Disability (Form 1099-SSA)
• Pension/Retirement/Annuity Income (Form 1099R)
• Interest Income (Form 1099INT)
• Dividend Income (Form 1099DIV)
• Rental Income (Schedule E)
• Self-Employed Income (Schedule C)
• All other Miscellaneous Income

3. Proof of Employment/Unemployment needed (include all that apply):
• Notice from Unemployment
• Termination Letter
• Pay Stubs

4. Rental Information needed:
• Full copy of signed lease
• 3-Day Notice and/or Eviction Notice
• Rent Invoice (if applicable)

Electronic Signature Consent

You must agree to consent to use our electronic signature to continue using this online form. If you prefer not to use an electronic signature, refer to the document for an alternative method.
Review this document carefully, your responses and signature will be applied to it:
Applicant/Client Full Name: *

First Name Last Name
Accept or decline the terms of the Consent for use of Electronic Signature Agreement *

I accept I decline
Before proceeding: Please have the following available to expedite your application. Have these on your computer from electronic documents, scans or take clear photos with your phone:
- State issued ID for all adult household members.
  Social security cards for all household members.
  Birth certificates for all household members.
  Proof of income/unemployment.
  Copies of past-due utility bills (if applicable).
  Copy of lease or mortgage (if applicable).
Signature *

Clear
Date

Month Day Year
Date
Household name

APPLICATION CANCELLED

Because you have declined our electronic signature consent, you cannot complete an electronic application.

To receive a printable application via email, write to paperforms@ccdosp.org.

To receive a paper application by mail, write to paperforms@ccdosp.org and state if you prefer a printable packet or paper forms mailed to you. If you prefer to receive the packet by mail include your full name, permanent Florida state address, and a brief description of the services you are applying for.

You may click the Back button and change your response or close your browser.

INTAKE CLIENT CONSENT OF SERVICE
I, Name

First Name Last Name
, hereby certify that the statement regarding household income (including report of 0 income) is true and complete to the best of my knowledge and is given under penalty of perjury. All other statements on my application are true and complete to the best of my knowledge.

WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements of misrepresentation to any Department or Agency of the United States as to any matter within its jurisdiction.

I understand that my fee for service(s) is $0.00. I hereby consent to Catholic Charities DOSP, Inc. and their agents to treat or provide services.
Hidden Date

Month Day Year
Date
Signature of Client/Parent/Guardian *

Clear

CATHOLIC CHARITIES, DIOCESE OF ST. PETERSBURG, INC.
HIPAA NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
Review this document carefully, your responses and signature will be applied to it:
I,

First Name Last Name
, hereby acknowledge that I received a copy of the Catholic Charities Notice of Privacy Practices.
Signature *

Clear
Hidden Date

Month Day Year
Date
Hidden Date

Month Day Year
Date
Description of Representative's Authority

Rights & Responsibilities
Review this document carefully, your responses and signature will be applied to it:
Signature of Client or Client's Representative *

Clear
Hidden Name

First Name Last Name

	Monthly $amt
Earned income (wages/salary)
Alimony/spousal support
Child support
Disability insurance
General assistance
Pension
SSDI
TANF
Unemployment insurance
Workers compensation
VA compensation
VA disability
Other income source(s)

	Monthly $value
TANF child care svcs
TANF transportation svcs
Other TANF
SNAP
WIC

Self Certification of Residency
I, *

First Name Last Name
, hereby certify that the below address is my permanent residence:
I hereby certify that the statements are true and complete to the best of my/our knowledge and belief and are given under penalty of perjury.

WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements of misrepresentation to any department or Agency of the United States as to any matter within its jurisdiction.
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
hidden name certification of residency

First Name Last Name
Client's Signature *

Clear
Hidden date certification of residency

Month Day Year
Date
Residency Applicable?

Pasco County Release of Information

Pinellas Homeless Management Information System - Release of Information
Review this document carefully, your responses and signature will be applied to it:
Provider Name
I authorize the use or disclosure of personal information, including protected health information, about the individual named above. *

I am the individual named above I am a personal representative because the person is a minor, incapacitated, or deceased
By signing this authorization, I am attesting that I understand: (Initial each line)
The reason I am being asked to release information. *
My protected health information, including, but not limited to, mental health, drug & alcohol, HIV/AIDS information can be shared with partner providers and HMIS participating organizations. I understand that agencies participating may change from time to time and that a copy of the current list of agencies is available upon request from the Coalition for the Homeless of Pasco County, Inc. at 727-842-8605. *
The HMIS operates over the internet and uses many security protections to ensure the complete confidentiality of my records. *
Signing this authorization is voluntary, and I do not have to agree to authorize any use or disclosure. I understand that the ability to receive services or support is not conditioned upon authorizing this disclosure. However, by not giving authorization to share information, I may not be able to access housing help as quickly as possible and that some services that result from a coordination of activities between providers may be limited in availability. Some agencies require certain questions to be answered in order to determine eligibility for their projects. *
The providers that have access to my protected health information are prohibited from re-disclosing information outside of the terms of his release of information form, without my written authorization except as permitted by federal or state law. *
Signature *

Clear
Date

Month Day Year
Date

All Adult Members and Dependent(s) that the Legal Guardian Authorizes to Participate in the HMIS:

	Name	Date of Birth
Household Member Applicant
Household Member #2
Household Member #3
Household Member #4
Household Member #5
Household Member #6
Household Member #7
Household Member #8

Affidavit of Duplication of Benefits With Recipient

Pasco H.E.A.R.T.
Review this document carefully, your responses and signature will be applied to it:
Hidden Agency name
Hidden Agency phone
Hidden Agency email
List all adult household members *
All Adult Household Members Must Sign
Recipient #1 *

Clear
Recipient #2

Clear
Recipient #3

Clear
Recipient #4

Clear
Recipient #5

Clear
Date

Month Day Year
Date
Hidden name SELF CERT OF ASSETS

First Name Last Name
Hidden ssn SELF CERT OF ASSETS

Self Certification of Assets
Review this document carefully, your responses and signature will be applied to it:

Checking/Savings Account Information: *

	Checking or Savings	Current Balance $amount	Account number
Account 1
Account 2
Account 3

Assets *

	Type	Cash value	Assessed value	Fair market value
Real Estate (combine if multiple)
Personal Property (vehicles, boats, etc)

Life Insurance *

	Type	Cash value	Valuation Date
Life Insurance

Pension, Annuity, Retirement Account *

	Type	Cash value	Dividend/Interest
Type
Other

Vehicles *

	Year	Type	Cash Value
1
2

Hidden name SELF CERT OF ASSETS 2

First Name Last Name
Hidden name SELF CERT OF ASSETS 3

First Name Last Name
Assets *

I have no assets I have no additional assets (other than those already listed above)
Signature *

Clear
Hidden Date SEL CERT OF ASSETS

Month Day Year
Date

Self Certification of Zero Income

To be completed by adult household members, if appropriate.
Hidden NAME SELF CERT ZERO INCOME 1

First Name Last Name
Hidden NAME SELF CERT ZERO INCOME FAMILY NAME

First Name Last Name
Hidden Name SELF CERT ZERO INCOME 2

First Name Last Name
Review this document carefully, your responses and signature will be applied to it:
1. I hereby certify that I do not individually receive income from any of the following sources:

a. Wages from employment (including commissions, tips, bonuses, fees, etc);

b. Income from operation of a business;

c. Rental income from real or personal property;

d. Interest or dividends from assets;

e. Social Security payments, annuities, insurance policies, retirement funds, pensions, Supplemental Security Income (SSI), or death benefits;

f. Unemployment or disability payments;

g. Public assistance payments;

h. Periodic allowances such as alimony, child support, or gifts received from persons not living in my household;

i. Sales from self-employed resources (Avon, Mary Kay, Shaklee, etc);

j. Any other source not named above.

2. I currently have no income of any kind and during the next 12 months there is no change expected in my financial or employment status.

3. I will be using the following sources of funds to pay for rent and other necessities:
*
In response to #3; what funds will you use to pay for rent and other necessities?
Signature *

Clear
Hidden date SELF CERT ZERO INCOME

Month Day Year
Date

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The following documents may all be required to process your application. Provide all that are available to expedite your application's review:

☐ Government-issued ID for all adults in household ages 18 and older

☐ Birth Certificate, SS card, shot record or school ID for all children in household ages 17 and under

☐ Application form signed by all adult household members

☐ Signed HMIS authorization release form listing all household member

☐ Duplication of Benefits form signed by all adult household members

☐ Valid, complete, signed rental agreement (even for utilities only)

Proof of Income/Unemployment (provide all that apply)

☐ Paystubs (2 months)

☐ 2020 Income Tax Return

☐ 2020 W-2 Forms

☐ 2020 1099 Forms

☐ 2021 SSI Award Letter

☐ Unemployment verification

If applying for rental assistance:

☐ Lease and assistance request dates correspond to program eligibility time frame

NOTE: Any past due amount cannot have occurred prior to March 13th, 2020.

☐ Leased property does not have homestead exemption (verify through Pasco County Property Appraiser’s website): https://search.pascopa.com/

☐ Parcel ID card from Pasco County Property Appraiser website

☐ Rental Authorization form completed by landlord (ensure it matches lease information)

☐ W9 form completed by landlord (ensure it matches lease information)

☐ Duplication of Benefits form signed by landlord.

If applying for utility assistance:

☐ Copy of Utility statement(s) to include:

- Customer name

- Account number

- Service address corresponding to property address

- Amount due

☐ Copy of any statement(s) corresponding to past-due amount for which assistance is requested

NOTE: Any past due amount cannot have occurred prior to March 1, 2020. Applicant must provide all bills corresponding to any past-due amount. Future utility payments are not eligible for H.E.A.R.T. assistance
Upload required documents from your computer

Browse Files

Cancel of
Take Photo of ID if you are applying on a smart phone:

1. Review your application:

Using the page navigation buttons, review your application carefully and correct any errors.

If you do not wish to apply or use electronic signature click Delete all/cancel application. None of your data will be stored or submitted and your application will not be processed. This can not be undone.

2. Submit your application:

After completing step 1, sign the confirmation below and click the Submit button below.

You cannot submit an unsigned application. If the submit button does not display, enter your signature.

What happens next?

After you click the Submit button, check your email for our acknowledgment. Please read that email carefully to verify no additional data is required to expedite your application. Depending on available funds, our funding sources may require additional information from you.

Do not complete multiple applications, your applications will be combined and you will lose your place in line.

Do not call, you will be contacted by a Case Manager. Calling will only slow down the processing of your application.

The acknowledgment email is confirmation that your application has been received and will be processed in the order of receipt.
I confirm I have reviewed my application, I confirm my responses and agree to the terms and conditions shown to me throughout this application: *

Clear
Optional comments for your Case Manager
EmailCalculation
example@example.com
Do not close the webpage or click the back after submitting your application. Please wait until the webpage is finished uploading. You may save the application prior to submitting it by clicking the Save button.
Should be Empty:

	Name	Mobile Phone	Other Phone	Relationship
1
2

	Name	Relationship to Head of Household	Last 4 #s of SSN	Age	Sex	Race	Disabled	Veteran Status
1
2
3
4
5
6
7

	Name	Student Y or N	Source of Income (include employer name if employed)	Payment Basis: Weekly	Amount
1
2
3
4
5
6
7

	Name	Date Became Unemployed	Reason for Unemployment	Eligible for Unemployment Benefits Yes or No	Name & Telephone # of Former Employer
1
2
3
4
5
6

CCDOSP Service Assistance

INTAKE CLIENT CONSENT OF SERVICE

HIPAA NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION

Rights & Responsibilities

Release of Information

Living Situation/Homeless Data

Self Certification of Residency

Pasco County Release of Information

By signing this authorization, I am attesting that I understand: (Initial each line)

Affidavit of Duplication of Benefits With Recipient

All Adult Household Members Must Sign

Self Certification of Assets

Self Certification of Zero Income

Application and Income Certification Form -2021

Review Statements to Initial and Sign

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