CCA Pre Application

Disruptive Client Behavior Policy

Combined Community Action is a private, non-profit organization serving low-income individuals and families over multiple counties in Central Texas. CCA staff are trained and certified in their respective programs and must apply the rules and regulations of each program to meet the specific need(s) of eligible families.

CCA reserves the right to deny assistance to a family for any disruptive behavior towards staff or other community members while on CCA property or during a home visit conducted by CCA staff/volunteers.

Disruptive behavior is defined as, but not limited to:
- Any type of physical confrontation or threatening behavior.
- Belligerent behavior or other verbal abuse to include swearing or foul language.
- Sexual Harassment towards any staff or CCA client
- Racism, sexism, homophobia, xenophobia, transphobia or any other derogatory remarks
- Theft from agency or staff member
- Being under the influence of alcohol or other substances.
- In the instance of home visits, illegal or unsafe behaviors in the home.

Once denied based on these behaviors, your household will not be allowed to reapply for services within Combined Community Action for a period of 1 year. Documentation of the violation will be maintained in household’s file. Household has the right to appeal in writing to the Program Director within 10 days of the violation.

Combined Community Action

www.ccaction.com Pre-Application (CEAP/CSBG/LIHWAP)
Date

MonthDayYear
Date
County:
First Name*
Last Name*
Phone Number*
House Number (No PO Box)*
Street Name*
Apt#
City*
Zip*
Email address
example@example.com
HOUSEHOLD COMPOSITION & CHARACTERISTICS

List the Head of Household and all other people currently living in the home. Indicate the relationship of each family member to the Head of Household. If you have additional family members, please include them in the 'Additional Information' section.

List each person in the household, including yourself.

	Household Member Name	Relationship to Head of Household	Race	Sex	Highest Level of Education	Date of Birth	US Citizen* Yes/No
Self
Person 2
Person 3
Person 4
Person 5
Person 6
Person 7
Person 8
Person 9

* presence (or absence) of US citizen in household does not automatically disqualify a household from service.

INCOME INFORMATION

Includes all wages (i.e. salaries, unemployment benefits, part-time income, seasonal income, Social Security, Supplemental Security, and any other income or benefits your household may receive)

List all income sources. If you need additional lines, please add the information to the 'Additional Information' area further along the form

	Household Member Name	Source of Income (include employer's name)	Amount of Gross Income for 30 days prior to application date
Income 1
Income 2
Income 3
Income 4

Name of your Electric Provider
Name of your Gas/Propane Provider (if you use to heat your home)
Name of your Water Provider
What type of place do you currently live in?

ApartmentHouseMobile Home
Are you interested in self-sufficiency case management services?

YesNo
DESCRIBE NEED FOR ASSISTANCE If you are not asking for utility assistance, please specify what type of assistance you need. Assistance for emergency services (rent, temporary shelter, deposit, etc) is very limited and not guaranteed. If you have a disconnect notice, upload it below.
File Upload

Cancelof
Use this space to list additional household members, income sources, or any information that is relevant to your application.
CCA will contact you by phone for additional documentation. Completion of this request does NOT guarantee assistance. Assistance is based on applicant being eligible, AVAILABILITY of funds and available appointments. An incomplete pre-application can be DENIED.
I CERTIFY THAT THE INFORMATION PROVIDED ON THIS APPLICATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF
(Applicant's Signature)

Clear
(Date)

MonthDayYear
Date
Should be Empty:

Combined Community Action