NHDC Intake Form

REQUEST FOR ASSISTANCE

633 NW 8th AVE. GAINESVILLE, FL TEL: (352)380-9119
Date*

MonthDayYear
Date
How did you hear of our agency if you were referred which agency specifically referred you: *
Referral Source?
Name*

First NameLast Name
Social Security Number*
Birthday*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Assistance Needed. (choose one):*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What county do you live in? *
Homeless Under Federal StatutesAt Imminent risk of homelessnessStably housedClient Refused
One night or lessTwo to six nightsOne week or more, but less than one monthOne month or more, but less than 90 days90 days or more, but less than one yearOne year or longerDon’t KnowRefuse to Answer
Female headed single parent householdMale headed single parent householdSingle adultTwo or more unrelated adultsMarried with childrenMarried without childrenOther
Total Number of Persons in Household:*
Place not meant for HabitationEmergency Shelter Hotel/MotelRental with subsidyRental without subsidyOwned by Client
Name of all Dependent Children or family members in household include DOB and SSN, RACE, Male/Female, Relationship to Head of Household (Ex: Son/Daughter)*
YesNo
WhiteBlack or African AmericanNative Hawaiian/ Pacific IslanderAmerican Indian/Alaskan NativeAsianOther
SingleMarriedDivorcedSeparatedWidowedOther
Are you a Veteran or household member is a veteran? (Please type name of veteran or N/A*
If Yes Branch name of the era Ex: Vietnam*
If you served, please give your Branch of Service, Dates of Service and Discharge status*
Biological Sex *
Affidavit of Hardship (Please explain what circumstances caused your current hardship)*
Risk of evictionRisk of lease terminationLiving “doubled up”, or in a residence that isn’t permanent for youStruggling to pay rent and utilities, or rent and utilities are more than your household can affordRelying on credit cards or depleting savings to pay for rent or utilitiesStruggling to pay for essentials such as food, prescription drugs, childcare or transportationOther
DO YOU HAVE HEALTH INSURANCE IF SO NAME OF INSURANCE DO CHILDREN HAVE HEALTH INSURANCE IF SO NAME OF HEALTH INSURANCE? IF YOU DO NOT HAVE HEALTH INSURANCE PLEASE EXPLAIN. PLEASE NOTE WE NEED THIS ANSWERED FOR ALL KIDS AND ADULTS IN YOUR HOUSEHOLD. *
Landlord Information
Name/address/phone number & email of landlord we will be reaching out to them to get more documentation. Have you informed the landlord that you are applying for assistance? *
Time at current address WHEN DID YOU SIGN YOUR LEASE/MORTGAGE AGREEMENT*
PROGRAM SPECIAL NEEDS INTAKE THESE ARE HUD RELATED DATA ELEMENTS
Are you Disabled?*
If you answer Yes for Disabled?
YesNoDon't knowRefuse to answer
YesNoDon't knowRefuse to answerN/A
YesNoDon't knowRefuse to answer
YesNoDon't knowRefuse to answerN/A
YesNoDon't knowRefuse to answer
YesNoDon't knowRefuse to answerN/A
YesNoDon't knowRefuse to answer
YesNoDon't knowRefuse to answer
YesNoDon't knowRefuse to answer
YesNoDon't knowRefuse to answerN/A
YesNoDon't knowRefuse to answer
YesNoDon't knowRefuse to answerN/A
YesNoDon't knowRefuse to answer
Within the past 3 monthsThree to six months agoSix months to one year agoOne year ago or moreDon’t KnowRefuse to Answer
YesNoDon't knowRefuse to answer
EMPLOYMENT/INCOME INFORMATION
Primary Employer: *
Title:
Hire Date

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Part-TimeFull-Time
Gross Income (before taxes): $
HourlyWeeklyEvery two weeksTwice a monthMonthly
YesNoN/A
YesNo
If yes, how long will it continue?
YesNoN/A

INCOME SOURCE LAST 30 DAYS*

Rows	Monthly Amount
Earned Income
Self-Employment
Child Support
Alimony Payments
Misc./Other.
SSI
SSDI
Unemployment
Retirement
Private Disability Insurance
Worker’s Compensation
Veteran’s Pension
Retirement Pension
TOTAL HOUSEHOLD INCOME

NON-CASH SOURCE LAST 30 DAYS (Enter zero if you don't receive any)*

Rows	Monthly Amount
Food Stamps (SNAP)
WIC
State Children’s Health Insurance
Medicaid Health Insurance
Medicare Health Insurance
TANF (Temporary Assistance)
VA Medical Services.
Section 8 Housing
Section 8 Utility Allowance
Temporary Rental Assistance
Misc.
Other
TOTAL Non-Cash:

Please list the approximate value of the following: (Enter zero for those you don't have any)*

Rows	Amount
Checking account
Savings account
Cash
CDs
Securities (stocks, bonds, etc.)
Retirement account
Other Liquid Funds

ASSET ADDENDUM TO APPLICATION

In order to properly qualify you for assistance, the income of applicants must be certified. The following asset information must be obtained. This information will be used to income eligibility purposes only.

Assets include: cash held in savings and/or checking accounts, trust funds, equity in real estate and other capital investments, stocks, bonds, Treasury bills, certificates of deposit money market funds, IRA accounts, retirement and pension funds, lump sum receipts (such as lottery winnings, insurance settlements, etc.) and personal property held as an investment (such as gems, coin collections, paintings, antique cars, rental property, etc.).

ASSETS DO NOT INCLUDE: necessary personal property such as furniture, automobiles, and clothing.
The total value of my (our) assets are: $*
The total annual income (interest, rent) received from these assets is: $*
Signature*

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Date

MonthDayYear
Date
FRAUD STATEMENT

Chapter 414.39 of Florida Statues makes it a crime, punishable by fine from both $50.00 to $5,000.00, or imprisonment for up to five (5) years, or both, if a housing applicant or resident deliberately makes false statements about his/her income or fails to disclose a material fact affecting income and rent.
Section 1001 of Title 18 of the United States Code also makes it a crime punishable by fine up to $10,000.00, or imprisonment up to five (5) years, or both for making any false, fictitious or fraudulent statement or representation making or using any false writing or document in any matter within the jurisdiction of any department or agency of the United States.

This means that if you, as an applicant, knowingly give Neighborhood Housing & Development Corporation (NHDC) false information about your household’s income including wages earned, child support, cash assistance from any source, retirement income, SSI or SSDI or changes in your family’s composition (family size) at the time of your application, your application will be deemed ineligible and you may be charged with fraud under Chapter 414.39 and/or Section 1001 of Title 18 of the United States Code.

If as a result of committing fraud, withholding information, or making a misrepresentation to NHDC, you receive any rental assistance, utility assistance or deposit assistance to which you are not entitled, you will be subject to local, state, and federal prosecution. THIS COULD RESULT IN A FINE, IMPRISONMENT OR BOTH AS WELL AS THE LOSS OF YOUR ELIGIBILITY FOR ASSTANCE FROM THIS AGENCY.
I have read the above statement AND I also understand the consequences of not correctly reporting my income, household size, or any other requirement of NHDC.
Signature*

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CERTIFICATION OF NO INCOME ONLY SIGN IF YOU HAVE NO INCOME

If you have claimed that you or the other household members indicated that you do not have any income you may certify by signing below that they have no income.

I certify that the information provided is true and accurate to the best of my knowledge. I understand that misrepresenting household income may constitute fraud. If I indicated that my household has no income, I affirm that is accurate and I understand that I may be asked for additional information and documentation to determine eligibility, which may delay the processing of my application.

I understand that providing false, misleading or incomplete information may result in ineligibility for this program, repayment or recapture of funds, and other legal action.
Signature

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Sustainability Participation Acknowledgment

I understand that the goal of this program is not only to prevent eviction or utility shutoff, but also to support me in achieving long-term housing stability.

I agree to cooperate with housing stability services offered by NHDC CARES if I am receiving more than one month of rental or utility assistance. These services may include referrals to job training, benefits enrollment, budgeting support, or other resources to help me maintain my housing.

I understand that refusing to participate in these services without good cause may affect my eligibility for continued assistance through the program.
Signature*

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Date*

MonthDayYear
Date
AUTHORIZATION AND CONSENT TO COLLECT AND RELEASE INFORMATION
I understand that Alachua County CoC Service Providers are part of the Bitfocus and Marion County CoC are part of Wellsky Network, designed to collect and share information to reduce the amount of time and effort it takes for me to obtain the requested services I need. CoC participating agencies have policies and procedures in place to protect confidential information. I authorize the agency providing a service to disclose to appropriate entities any information regarding my general condition, past and present, and/or information about other family members or other residents contained in the application concerning services provided to and/or requested by me and others I have listed on the application. This consent may be revoked by me or any other family member or resident, at any time except to the extent that action has been taken in reliance thereon. This consent unless expressly revoked earlier will expire four years from the date indicated below. I declare that the information I give is true and correct to the best of my knowledge. Upon request, I will be provided a copy of the Full Privacy Notice. Further NHDC besides releasing information to CoC/Well Sky partner, with my permission as expressed by the signing of this Release may provide information including the intake form to other agencies not a part of WellSky. These other agencies/organizations to assist with the furtherance of assistance to me and/or my family.

KEYS TO HOME FL-508 CONTINUUM OF CARE (CoC) CLIENT ACKNOWLEDGEMENT FOR ELECTRONIC DATA COLLECTION IN HOMELESS MANAGEMENT INFORMATION SYSTEMS (HMIS)
Agency Name: Neighborhood Hoursing & Development Corporation IMPORTANT: Non-victim service providers may enter clients who are receiving services from a domestic violence (DV) agency into HMIS, provided that:

1.       The client is not receiving DV-related services from the non-victim service provider, and

2.       The client has given informed, written consent to have their personally identifying information (PII) entered.

However, clients who do not consent, or who are currently fleeing or in danger from domestic violence, dating violence, sexual assault, or stalking, must not have PII entered into HMIS.

This agency is a partner in the Taskforce Fore Ending Homelessness, Inc. Keys to Home FL-508 Continuum of Care (CoC) HMIS. CoC HMIS partner agencies work together to provide services to persons and families who are experiencing homelessness. When you request or receive services, we may collect data about you and your household that may be shared with other CoC HMIS partner agencies. Sharing your data allows service providers to see if they have housing services that fit your needs and for the purpose of ensuring effective coordination of services. It does not guarantee that you will receive housing.

Who can have access to your information?

Agencies and/or organizations that participate in the HMIS Database can have access to your data. These agencies and/or organizations may include homeless service funders/providers, housing providers, healthcare providers, and governmental agencies. Additional agencies and/or organizations may join the Keys To Home FL-508 CoC HMIS at any time and will also have access to your data. The current list of agencies and/or organizations are listed in the attached Exhibit – A.

How will my data be protected?

Your information is protected by the federal HMIS Privacy Standards, is secured by passwords and encryption technology and the HMIS application incorporates industry standard security protocols and is updated regularly to meet these security standards. In addition, each participating organization has signed a Contributing HMIS Organization (CHO) agreement to maintain the security and confidentiality of the information. In some instances, when the participating organization is a health care organization, your information may be protected by the privacy standards of the Health Insurance Portability and Accountability Act (HIPAA).

How do I benefit by providing the requested information and sharing it with other agencies?

By sharing your information with other agencies, you may be able to avoid being screened again, get services faster, and minimize how many times you have to tell your “story.” You also help agencies document the need for services and funding.

Client Informed Consent/Authorization for Release of Information (ROI)
·         When you sign this form, it shows that you understand the following: We collect personal information about the people we serve in a computer system commonly known as Clarity and BitFocus (“BF ”). BF is used by agencies which provide homeless prevention, shelter and housing related services in the Keys To Home FL-508 CoC. Agencies using SP comply with all the requirements related to keeping your personal information private and secure.

·         We use personal information to run our programs and help us improve our services. Also, we are required to collect some personal information by organizations that fund our program.

·         Your information will help us get the appropriate services for you through our program(s) offered by other agencies.

·         You agree to share Protected Personal information and general information obtained during your intake and assessment, which may include but is not limited to: name, date of birth, social security number, demographic information such gender and ethnicity/race, veteran status, residence information (history of homelessness and housing), marital status, household relationships, disability status, self-reporting medical history including any medical health and substance abuse issues, assessment date(s), income sources and amounts, non-cash benefits, case notes, services needed and provided, outcomes of services provided, emergency contact information, and your photo.

·         This consent form expires three (3) years from the date of signature.

·         You have the right to revoke this consent at any time by writing to this agency. However, the revocation will not be retroactive to any information that has already been released.

·         You have a right to review the information that we have about you. If you find mistakes, you can ask us to correct them.

·         You have the right to file a complaint if you feel that your privacy rights have been violated.

·         This consent is voluntary. You will not be denied services if you refuse to sign this consent form.

·         There is a risk of a security breach, and someone might obtain my information and use it inappropriately.

·         If you would like a copy of our privacy policy, our agency staff will provide one.

I hereby attest that I have read and fully understand the information presented above. I acknowledge that I have had the opportunity to ask questions and seek clarification regarding any aspects I did not understand. By signing below, I confirm my agreement to the terms and conditions above:

Exhibit - A

Participating Agencies and/or Organizations:

·         Alachua County Coalition for the Homeless and Hungry | dba GRACE Marketplace
·         Alachua County Board of County Commissioners| Alachua County Community Support Services
·         Alachua County Housing Authority
·         Catholic Charities - Gainesville
·         Catholic Charities - Putnam
·         CDS, Family & Behavioral Health Services, Inc.

·         City of Gainesville – Fire Rescue
·         Family Promise Gainesville
·         Meridian Behavioral Healthcare, Inc.
·         Neighborhood Housing Development Corporation
·         PCSC | Heart of Putnam Service Center

·         Putnam County Caring Coalition

·         Release Reentry
·         SFH | St. Francis House

·         TaskForce Fore Ending Homelessness, Inc. (CoC Lead)
·         The Veteran Administration of Gainesville
·         Volunteers of America | GPD Programs
·         Volunteers of America | SSVF Programs
Option 1 - Allow NHDC to share my personal information with third parties deemed necessary for the counseling services being provided.Option 2 - Limit disclosure of personal information about me to unaffiliated third parties other than nonprofit organizations involved in community development.Option 3 - Limit disclosure of personal information about me only to funders, government agencies or nonprofit organizations involved in community development that are used only for program review, auditing, research and oversight purposes.
Applicant's Full Name*

First NameLast Name
Co-Applicant's Full Name

First NameLast Name
Applicant's Signature*

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Co-Applicant's Signature

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Date*

MonthDayYear
Date
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REQUEST FOR ASSISTANCE