Emergency Assistance Application

Emergency Assistance Application

Please be sure to first apply for the State Emergency Relief program through the Michigan Department of Health and Human Services (MDHHS) by calling 1-844-464-3447 or online at newmibridges.michigan.gov
Name*

First NameMiddle InitialLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
How would you like us to contact you?
By selecting I consent, below, I agree to being contacted via text message and/or email through a secured database for the purpose of obtaining the necessary documents required to process my request.

I consent
Phone Number*
Please enter a valid phone number.
Email
example@example.com
How did you hear about us?*
Emergency need
Explain your emergency need?*
.
Marital Status*
Date of Birth*

MonthDayYear
Date
Social Security Number:*
000-00-0000
County*
Are you a veteran?*

YesNo
Propane Carrier

Do you receive Food Assistance/Supplemental Nutrition Assistance Program benefits?*
MDHHS Case Number*
If no case number enter 0000

Household Members

Include everyone living in the household. Please start with yourself.
Household Members*
Type of Health Insurance*

Income Verification

Include all household income.
Acceptable Proof Of Income

Earned Income: Be sure all pay stubs are clear. Employee's name, employer/source name, dates of pay period, and gross amount of pay (including tips if applicable) must all be legible.
- Pay Stubs: Provide number of pay stubs dependant on how often recieved.
  - Weekly - 5 pay stubs
  - Bi-Weekly - 3 pay stubs
  - Monthly - 2 pay stubs
- Self-employed individuals must provide the previous year's state income tax forms, including profit and loss statement as proof of income.
Unearned Income: (No Bank Statments)
- SSI, Social Security, RSDI, SSDI : Must provide 2022 benefit award letter.
- Quarterly SSI Supplemental verification
- Pension Letter/statement.
- Veteran Benefits Awards Letter
- Child Support: Must provide MICase print off showing past 90 days of income.
- Unemployment: Must provide current UIA print off or UIA Award Letter.
- Cash Assistance: Provide DHHS Case Action Letter showing past 90 days.
- Adoption Subsidy/Direct Care through the State: Provide copy of pay stubs for past 90 days.
- Worker's Compensation: Provide 90 days of pay stubs.
- Alimony or Spousal Support: Provide Divorce agreement or MICASE statement.
- Adoption Subsidy/Direct Care letters.
- Interest, Annuities, or Dividends.
- Rental Income : Provide statements and reciept.
- Other Income: Cash from employment, cash from friends or family, ect. (A written statement including employer/family member name, address, and phone number must be provided)
Does household have income?*

YesNo
Household Income
Annual Gross Household Income*
Annual Gross Household income
Has there been any, or do you expect any changes in your household's income in the next 30 days? (Please provide verification from employer of this change)*
If previous answer was yes explain.
Required Information for Requesting Service(s)

Please upload all paperwork that applies to your situation.
Include With Every Application:
- Valid Driver’s License or State issued ID or School ID or US Military Card or US Passport
- Social Security Card for applicant and/or name on bill
- DHHS decision letter
- Proof of income/ Benefit award letter ( FAP,SNAP or SER)
Include If Needing Help With Utility/Propane Assistance: Please note-
- Utility shut-off notice
- Propane Client/Account number
- Please Note: Payment for deliverable fuel will not be made if, upon delivery, it is confirmed you have more than 25% remaining in your tank. You will then be responsible for the cost of delivery.
- Propane Assistance is unavailable after April 1st or when funding is exhausted
Include If Needing Help With Rental Assistance, Evictions, Deposit:
- Lease
- Eviction Judgment
- Proof of Housing Assistance Voucher Approval
- Proof of apartment approval stating cost of 1st months rent and Security Deposit
Include If Needing Help With Metered Water/Sewer Assistance:
- Water bill- past due/shut off
- Proof of income/ Benefit award letter ( FAP,SNAP or SER)
Missing documents will delay the emergency assistance decision.
Upload Required documents*

Cancelof
Consent/Release of Information

I, {name} consent to release, obtain and share all pertinent information and non-confidential social, medical, and other information about myself and information I have provided about additional family members that will allow me and my family to benefit from services offered. In granting such permission, I understand that such information will remain confidential and that such information will only be used for my benefit or to benefit other members of my family. Only authorized personnel will share client information needed for service delivery, to track demographic trends, service patterns and the client outcomes achieved. I further understand that information regarding myself and additional family members will be entered into the data management system(s) utilized by EightCAP, Inc.

I release EightCAP, Inc. and its staff from any legal liability for disclosing or acquiring information that I have permitted by signing this form.

I {name}authorize contact with the following agencies to aid in the solution to my emergency.

Your local Department of Health and Human Services (DHHS- State Emergency Relief payment authorizations and Benefit communications)
Community Management Associates (CMA- HCV voucher verifications and referrals)
Community Mental Health (CMH- Referrals to programs offered with authorization from applicant)
Property Management (Residence verification and payment authorizations)
Community Action Agencies (CAA- Communications to assist with other agencies to aid in emergency situation solutions)
Utility Providers (View and obtain most recent utility bill, provider payment programs and payment authorizations)

EightCAP, Inc will only utilize the appropriate agencies to assist in the resolution of the emergency assistance requested.

First Name
I First Name Last Name understand I may be asked to provide information about my experience participating in an assistance program as a grant requirement for assistance.
First Name*
By signing below, I understand that unless I make a formal request to EightCAP, Inc. that I no longer want to participate in the services offered; this release will remain in effect for (1) year from today.

The statements made by me are true, correct, and complete to the best of my knowledge.
Signature*

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Make sure to sign or application will not be accepted.
Date*

MonthDayYear
Date
In accordance with federal and state laws, EightCAP, Inc. shall provide equal opportunity to its services and programs without regard for age, color, disability, familial status, experience, gender, gender identification or expression, formal education, hanidcap, height, marital or parental status, military service, national origin including limited English Proficiency, political affiliation, race, religion/creed, sex, sexual orientation, or weight. Financial assistance is not guarenteed. Any financial assistance provided is based on EightCAP,Inc guidelines and limitations.
Should be Empty:

Emergency Assistance Application

Household Members

Income Verification

Required Information for Requesting Service(s)