ARPA Assistance Application & Agreement

ARPA Assistance Application & Agreement

ONLY FOR COBB COUNTY RESIDENTS
Do you qualify to receive assistance through the ARPA grant?
YesNo
YesNo
YesNo

You are NOT ELIGIBLE for assistance through the ARPA Grant. This grant is only available to Cobb Residents who are in ACTIVE cancer treatment.

You may be eligible to receive other assistance through our organization. Please refer to our website to learn more about our programs and services.

Please visit our Recources Page or visit the Cobb County website to learn more about the American Rescue Plan Act (ARPA)

If you have any additional questions please contact us

Email: info@lovingarms.support

Phone: 770-590-5153

You are ELIGIBLE to apply to receive assistance through the ARPA Program.

PLEASE BE SURE YOU HAVE THE FOLLOWING INFORMATION AVAILABLE AT THE TIME OF COMPLETING THIS APPLICATION:
1. Patient Information
  1. Contact Info
  2. Photo ID (Drivers License or Passport)
2. Medical Information
  1. Oncologist Information (Doctor, Ph, Fax, Address)
  2. Treatment information (Date of Last Treatment)
3. Housing Information
  1. Current Lease/ Mortgage Agreement
  2. Rental/Mortgage Information
  3. Contact Information
4. Proof of Income
  1. Previous/Current Year Taxes OR Benefit Verification Letter (SSA)
  2. Last 3 Paystubs AND Bank Statements

ARPA Assistance Application & Agreement

ONLY FOR COBB COUNTY RESIDENTS
SECTION 1: PATIENT INFORMATION:
DATE OF APPLICATION*

MonthDayYear
Date
Full Name*
First and Last Names
Sex*
Home Address*
City*
State*
Phone*
Format: (000) 000-0000.
Email
example@example.com
SECTION 2: HOUSEHOLD INFORMATION
Please provide the following information per your last tax filing. You may be asked to provide additional information/ documentation if needed.
Total Number in Household*
Total Adults in Household*
Total Children in Household*
Total YEARLY HOUSEHOLD Income*
Total YEARLY PERSONAL Income*
SECTION 3: REQUESTED ASSISTANCE

THE HOUSING ASSISTANCE IS CURRENTLY PAUSED. CHECKING THE APPROPRIATE BOX BELOW DOES NOT GUARANTEE HOUSING ASSISTANCE. THE GROCERY ASSISTANCE IS CURRENTLY OPEN.
Rent/Mortgage AssistanceGrocery Assistance (Food Only Restricted)
SECTION 4: HOUSING INFORMATION

ONLY COMPLETE IF REQUESTING RENT/MORTGAGE ASSISTANCE
Please provide the information of person(s) listed on Rental Agreement/Mortgage:
Agreement Holder Full Name(s)
Account Number or Address
Total Monthly Payment
Relationship to Patient
spouse, parent, caregiver, friend, etc.
Agreement Holder Phone
Format: (000) 000-0000.
Agreement Holder Email
example@example.com
SECTION 5: LEASE/MORTGAGE INFORMATION

ONLY COMPLETE IF REQUESTING RENT/MORTGAGE ASSISTANCE
RENTOWN
Name of Lender/Property Management Company
Contact info for Lender/ Property Management
Contact Name
Contact Email
example@example.com
Please provide the following information for payment disbursement:

All payments are made by check and are to be picked up at Loving Arms office

Checks CANNOT be written to participants of ARPA program.
Make Check Payable To
example: Bank Name, Property Management, Property Owner
Total Monthly Payment
SECTION 6: PROOF OF INCOME
What is considered a low-income household?
ARPA guidelines define a “low-income household” as a household with income at or below 185 percent of the Federal Poverty Guidelines for the size of its household based on the poverty guidelines published most recently by the Department of Health and Human Services.

All applicants must provide proof of income to ensure eligibility for assistance through the ARPA program.

The following document(s) will be accepted as proof of income:

1. Last Tax Summary OR Benefit Verification Letter (SSA)

2. Last 3 Paystubs AND Banks Statements for the last 2 months
Last Tax Summary OR Benefit Verification Letter (SSA)Last 3 Paystubs AND 2 Months Bank Statements
SECTION 7: TERMS AND CONDITIONS OF AGREEMENT
Please initial next to each item to signify understanding and acceptance
1. All payments made by LACO shall be made directly to the appropriate company provided by the client.*
Initials Only
2. Proof of income, separation letter for a job loss, or any additional documentation will be provided by the client is requested by LACO.*
Initials Only
3. Aldi grocery cards can ONLY be used on food items,any non-food items will not be accepted by card.*
Initials Only
4. LACO staff reserve the right to decline a request at any time with proper notice to the client.*
Initials Only
5. All applications will be deemed incomplete until all paperwork is received and approved by staff.*
Initials Only
6. If client is residing with another person, additional information and documentation may be required.*
Initials Only
7. All person(s) residing with clients may be asked to provide documentation as requested by LACO.*
Initials Only
8. LACO may request a signed letter from an oncologist verifying past care/treatment at any time.*
Initials Only
By signing below I, Patient Full Name* agree to the terms and conditions and acknowledge
that all the information provided is true and correct to the best of my knowledge and I authorize Loving Arms Cancer Outreach to share my information with Cobb County and the Federal Government as they may require.
Client Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
SECTION 9: SUPPORTING DOCUMENTS & NOTES

Please provide the following documents
Current Lease/Mortgage Contract (1st Page & Signature Page)

Cancelof
Client Photo ID*

Cancelof
Proof of Income Documents*

Cancelof
Current RENT/MORTGAGE Bill (Must reflect current balance for the month requesting assistance. Ledger, Invoice, letter from leasing office, etc. )

Cancelof
Other supporting documents

Cancelof
Is there anything else you would like us to know? Please include your detailed message here:
Should be Empty:

ARPA Assistance Application & Agreement

ARPA Assistance Application & Agreement

SECTION 1: PATIENT INFORMATION:

SECTION 2: HOUSEHOLD INFORMATION

SECTION 3: REQUESTED ASSISTANCE

SECTION 4: HOUSING INFORMATION

SECTION 5: LEASE/MORTGAGE INFORMATION

SECTION 6: PROOF OF INCOME

SECTION 7: TERMS AND CONDITIONS OF AGREEMENT

SECTION 9: SUPPORTING DOCUMENTS & NOTES