RELIANT APPLICATION

WAXAHACHIE CARE SERVICES RELIANT APPLICATION

WCS
WAXAHACHIE CARE SERVICES DOES NOT HAVE RENTAL FUNDS. ANY REQUEST FOR RENTAL ASSISTANCE WILL BE DENIED.
WAXAHACHIE CARE IS AN EQUAL OPPORTUNITY PROVIDER

Waxahachie CARE Services does not and shall not discriminate on the basis of race, color, religion, gender, gender expression, age, national origin, disability, marital status, sexual orientation, or military status, in any of its activities or operations.
Required Information

Our purpose is to help those in need. We service ALL of Ellis County.

WCS reserves the right to deny any application, with or without notification to the applicant.

Items REQUIRED - Screenshots will NOT be accepted:

1. Photo ID for all members of the household age 20+

2. Proof of residency

-If you rent: Lease/rental agreement
-If you own your home: mortgage statement

-CAD (County Appraisal District)

3. Proof of income for all members of the household age 20+

HANDWRITTEN INCOME WILL NOT BE ACCEPTED! WCS has the right to ask for bank statements and can ask in the event that more information is needed. Screenshots will not be accepted.

Types of, but not limited to, acceptable income:
1. Earned Income - 1 consecutive month of check stubs from current job
2. Social Security (SS)
3. Supplemental Security Income (SSI)
4. Social Security Disability Insurance (SSDI)
5. Retirement, Survivors, and Disability Insurance (RSDI)
6. Temporary Assistance for Needy Families (TANF)
7. Retirement/Pension
8. SNAP (ALL PAGES)
9. Women, Infant, Children (WIC)
10. Child Support Benefits
11. Veteran Benefits (VA)
12. Workman's Compensation
13. Unemployment Benefits
14. Family Support- provide proof from cash app, Zelle, Venmo, bank statements, etc.
15. Approval, Denial, and/or Pending Letters
Applicant Name*

First NameLast Name
Applicant Date of Birth*

MonthDayYear
Date
WAXAHACHIE CARE SERVICES BILL PAY AUTHORIZATION

I give permission for Waxahachie CARE Services (WCS) to access my utility account and to utilize what is necessary to pay my utility bill.

I give my consent that Waxahachie CARE Services (WCS) may share my information, if necessary, with other agencies in order to process the needed paperwork.

No unauthorized person will gain access to my information other than to process the payment of my bill.

I understand my name must be on the bill when requesting assistance. I understand that if my name is not on the bill or authorized user list within my utility company that WCS cannot provide utility assistance.
I have read the above in its entirety.*

YesNo
Provide a DETAILED explanation of your need. What is your household experiencing that you need to ask for assistance? WCS reserves the right to close this request if a detailed explanation is not provided, with or without notice.*
If you need assistance because of a job loss, medical condition, or if your unique situation needs further verification, the following MUST be provided.
1. If job loss: termination letter, workman's comp,
2. If medical condition: A Dr. Note stating you are not able to work at this time and stating when you can return to work. DO NOT SUBMIT MEDICAL DIAGNOSIS OR NAME OF MEDICATIONS, OR ANY OTHER SENSITIVE MEDICAL INFORMATION.
3. If EMERGENCY situation: Proper documentation/fire report/police report/etc.
4. If unique: documentation as to why
JOB LOSS, MEDICAL CONDITION, OR EMERGENCY SITUATION: DO NOT SUBMIT MEDICAL DIAGNOSIS OR MEDICATION. Screenshots will not be accepted.

If job loss: termination letter, workman's comp, If medical condition: A Dr. Note stating you are not able to work at this time and stating when you can return to workIf ER situation: Proper documentation/fire report/police report/etc.If unique: documentation as to why
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Please check which option you are seeking assistance for:*

Reliant
Bill Submission*

Complete bill must be provided. You can select multiple photos of bills. Screenshots will NOT be accepted.
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Photo ID or driver's license for ALL adults currently living in applicant's household, age 20+ *

Multiple files can be uploaded. DO NOT SUBMIT YOUR SOCIAL SECURITY NUMBER OR CARD.
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Are you a current WCS neighbor?*
Applicant Emergency Contact*
Name, gender
Relationship of Emergency Contact to you, the Applicant*

They are my spouseThey are my partnerThey are my parentThey are my friendThey are my live-InOther
Applicant Emergency Contact Phone Number*
Please enter your emergency contact's phone number
Applicant Apartment Complex Name*
Type NA if not applicable
Applicant Address*
Applicant City*
Applicant State*
Applicant Zip Code*
Proof of residency: FULL lease/rental agreement, mortgage statement, or County CAD record. Receipts will NOT be accepted. Mail/bills will NOT be accepted. Handwritten notes will NOT be accepted. Screenshots will NOT be accepted. *

multiple files can be uploaded
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Is your address in Glenn Heights? If YES, you MUST provide proof of being an Ellis County resident. No proof, NO services:*

YesNo
RESIDENTS OF GLENN HEIGHTS ONLY: Proof of Ellis County Residency (must say Ellis County)*

multiple files can be uploaded
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Applicant Phone Number*
Applicant Email Address*
example@example.com
Applicant Gender*
Applicant Ethnicity*

African-AmericanAsianCaucasianHispanicMiddle EasternNative AmericanPacific IslanderMultiracialNon US born - ImmgrantOther
Applicant Highest Education*

IncompleteGraduate/GEDSome CollegeAssociates/BachelorsMasters/PHD
Do you, the applicant, receive the following Government Income? CHECK ALL THAT APPLY*

SNAPMedicaidMedicareSocial Security (SS)Supplement Security Income (SSI)Social Security Disability Income (SSDI)Retirement, Survivors, and Disability Insurance (RSDI)PensionVeterans Benefits (VA)WICUnemploymentChild SupportNone of the above
Applicant Employment Status*

Full TimePart TimeStudentRetiredStay At Home ParentJob LossUnemployed
Applicant Employer*
Applicant City of Employer*
Paystubs For ALL Household Members age 20+*

Multiple files can be uploaded. One consecutive month's worth of pay stubs. Pay stubs must show pay period, employer name, employee name, ETC.
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College Student Schedule

Current Semester Schedule
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If unemployed, how long?*
Applicant Marital Status*

Married/Live-in/SeparatedSingleDivorcedWidow/Widower
SPOUSE INFORMATION
Spouse Name*

First NameLast Name
Spouse Date of Birth*

MonthDayYear
Date
Spouse Email Address*
example@example.com
Spouse Phone Number*
Please enter a valid phone number.
Spouse Gender*
Spouse Ethnicity*

African-AmericanAsianCaucasianHispanicMiddle EasternNative AmericanPacific IslanderMultiracialNon US born - ImmgrantOther
Spouse Highest Education*

IncompleteGraduate/GEDSome CollegeAssociates/BachelorsMasters/PHD
Is spouse considered to be any of the following? CHECK ALL THAT APPLY*

DisabledVeteranHomelessRetiredDeceasedOther
Spouse Date of Decease

MonthDayYear
Date
Spouse Employment Status*

Full TimePart TimeJob LossUnemployedStudentRetiredDeceasedOther
Spouse Employer*
Spouse City of Employer*
Does your spouse receive the following income? CHECK ALL THAT APPLY*

Pay StubsSNAPMedicaidMedicareSocial Security (SS)Supplement Security Income (SSI)Social Security Disability Income (SSDI)Retirement, Survivors, and Disability Insurance (RSDI)PensionVeterans Benefits (VA)WICUnemploymentChild SupportNone of the above
If spouse is unemployed, how long?*
Letters for ALL Household Members

Examples, but not limited to: Unemployment, resignation, termination, denial/pending cases for SNAP, SS, Child Support, ETC. Multiple files can be uploaded. WCS RESERVES THE RIGHT TO ASK FOR BANK STATEMENTS IF NEEDED.
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How many people are living in your household, INCLUDING you?*
OTHER FAMILY MEMBERS

Type NA if not applicable
ADDITIONAL HOUSEHOLD MEMBERS*
ADDITIONAL HOUSEHOLD MEMBERS*
ADDITIONAL HOUSEHOLD MEMBERS*
ADDITIONAL HOUSEHOLD MEMBERS*
ADDITIONAL HOUSEHOLD MEMBERS*
ADDITIONAL HOUSEHOLD MEMBERS*
NET MONTHLY INCOME FOR ALL ADULTS AGE 20+

One month's worth of pay stubs for all adults age 20+
EARNED APPLICANT*
EARNED SPOUSE*
Please read: I confirm that the information provided is complete and correct to the best of my knowledge. I am also aware that any attempt to obtain aid fraudulently from Waxahachie CARE Services will result in my application being denied and services suspended. I understand that any and all information supplied by me on this form may be verified.

This application does not guarantee any form of payment, pledge, or responsibility from Waxahachie CARE Services.
I agree to allow Waxahachie CARE Services to perform the following actions:
1. Use my demographic information in monthly statistical reports, county and city reports, and as needed.
2. Contact family members for clarification, if applicable.
3. Contact past and current employers to verify my employment status, if applicable.
4. Contact my apartment manager/landlord, utility providers, or any other contact to verify my situation, if applicable.
5. Contact other social service agencies on my behalf to network my efforts in receiving assistance, if applicable.
I agree to be respectful, and kind in ALL communication with Waxahachie CARE Services employees, volunteers, and representatives of WCS.
1. I understand WCS is NOT an allergy free facility, and even though WCS does their best to not cross-contaminate, it is understood WCS is not responsible for any allergy related reactions, on or off the premises.
2. I understand WCS cannot be held responsible for donated items received if they do not meet my expectations.
3. I understand that WCS has the right to terminate or deny services at any time, with or without contact or notice.
4. I will not use excessive profane language.
5. I will not use derogatory or negative language, including but not limited to, emoji's, hand gestures, pictures, verbal or written communications, etc.
6. I understand that it can take 7- 14 business days to review but not complete my request.
7. I understand any and all negative behavior will not be tolerated on the premises or within electronic communication.
8. I understand WCS is not government funded and I may not receive any assistance or services.
9. I understand written or verbal exchanges do not guarantee or promise full or partial pledges, payments, or assistance in any form.
10. I understand that WCS requires my picture to be taken for their records in order to receive services and/or assistance.
11. I understand that WCS may require a signed authorization form in order to potentially receive utility assistance.
12. I understand denied services is not discrimination or racism.
13. I understand WCS has many volunteers who do their best to accomodate phone calls and emails.
14. I will treat all people affiliated with WCS, on or off the premises, with respect and kindness.
15. I understand that if I fail to comply with any part of this application now or in the future, WCS reserves the right to immediatly void and close my request(s), application(s), and future services, with or without notice.
16. By signing this application I have read, understand, and agree to all requirements, procedures, and behavioral expectations.
Today's Date*

MonthDayYear
Date
By signing, I, the applicant, agree to ALL of the above*

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Agreement of WCS Neighbor Conduct

Due to ongoing negative and aggressive behavior toward WCS staff and volunteers, we are now enforcing the following. Please read carefully before signing.
This notice is to inform you that you MAY be terminated by the Waxahachie Care Services (WCS) Program immediately for the following offenses if committed by you, the applicant, any household member, or person(s) with you at the time of offense:

1. Belligerent or threatening behavior toward a staff member or any other person(s) while inside or outside of the WCS facility, including electronic communications.

2. Verbal abuse, including the use of profanity, at or in the presence of a staff member or any person(s) while inside or outside any WCS office, including electronic communications.

3. Any type of actual physical confrontation toward a staff member or any other persons(s) while inside or outside any WCS facility.

4. Providing false or misleading information regarding you or any household member(s).

5. Theft from agency or staff member(s) or any other person(s) while inside or outside any WCS facility.

I acknowledge that once terminated, I will not be allowed to reapply for any services with WCS for a period of 1 – 2 years depending on the severity of the violation. The ban from services will remain in effect even if the person(s) who committed the violation no longer uses WCS.

I acknowledge that all documentation regarding the violation will be maintained in my client file. IF a violation is committed, I shall have the right to appeal in writing to the Program Director within 10 days of violation.

I acknowledge that I may or may not receive financial assistance, including utility services and all other financial services. I am NOT guaranteed financial assistance from WCS.

I acknowledge that I need to always stay in a vehicle when on the premises of WCS. I will not exit my vehicle except to load my vehicle with my groceries and/or available items.

Upon reapplication for program services, Applicant has a responsibility to:

1. Provide required information to verify eligibility for assistance whenever the case is opened or reopened.

2. Report any changes in the household – income, number of people in the home, etc. which may affect eligibility.

3. Report any changes in utility provider when receiving utility assistance.
Today's Date

MonthDayYear
Date
Signature

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Should be Empty:

WAXAHACHIE CARE SERVICES RELIANT APPLICATION

WAXAHACHIE CARE IS AN EQUAL OPPORTUNITY PROVIDER

SPOUSE INFORMATION

OTHER FAMILY MEMBERS

NET MONTHLY INCOME FOR ALL ADULTS AGE 20+