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  • CCDOSP Service Assistance

    Service Application for Pasco H.E.A.R.T.
  • CCDOSP Service Assistance/general service application 

  • Enter your email address where you can receive an email now. All communication throughout your service will only be conducted through this address. 

    Copy and paste the code from your email to validate and continue.

  • 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. 

  • 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).
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  • 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

  • , 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.

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  • CATHOLIC CHARITIES, DIOCESE OF ST. PETERSBURG, INC.

  • HIPAA NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION

  • , hereby acknowledge that I received a copy of the Catholic Charities Notice of Privacy Practices.

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  • Rights & Responsibilities

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  • Release of Information

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  • Applicant Data 

    These entries will replicate throughout the application to speed the application process and reduce errors.  

    Be sure your entries on this page are correct as they will be used on binding documents. 

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  • The following data is used for grant applications and adminstrative purposes. Your responses are not considered in determining your eligibility for service. 

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  • Living Situation/Homeless Data

  • Self Certification of Residency

  • , 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. 

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  • Pasco County Release of Information

    Pinellas Homeless Management Information System - Release of Information
  • By signing this authorization, I am attesting that I understand: (Initial each line)

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  • Affidavit of Duplication of Benefits With Recipient

    Pasco H.E.A.R.T.
  • All Adult Household Members Must Sign

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  • Self Certification of Assets

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  • Self Certification of Zero Income

    To be completed by adult household members, if appropriate.
  • 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:

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  • Application and Income Certification Form -2021

    Pasco County Community H.E.A.R.T.
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  • Review Statements to Initial and Sign

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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

     

     

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    Cancel of
  • 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. 

     

     

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