Bear River Association of Governments - STEPS

Applicant,

This application is intended for households with children and at least one adult who is eligible and able to work in the United States. The goal of the Self Reliance Through Employment Pathway Services program is to help households achieve self sufficiency by stabilizing the household, exploring career opportunities and increasing household income and benefits

You must currently reside in Box Elder, Cache, or Rich Counties in order to qualify..

Household qualification is based on the 2024 National Poverty Guidelines. The poverty guidelines below are used to determine eligibility for the program. According to

Community Action Program Legal Services (CAPLAW), the income of all members of each individual family unit must be included in determining income eligibility.

Department of Health and Human Services - 2024 National Poverty Guidelines (150%) For Box Elder, Cache and Rich Counties (Based on Gross Monthly Income)

WARNING: Title 18, Section 1001 of the United States Code, states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department or agency of the United States.
Income for all household members must be disclosed or the application will be denied.

By signing below, I verify that the information I have provided is true and accurate to my knowledge. I understand that providing misleading or false information will result in denial or termination of assistance.

Consent for Coordinated Services & Release of Information

I hereby authorize Bear River Association of Governments (BRAG) to share information regardingservices my household and I have received or will receive with organizations relevant to my case. This mayinclude but not limited to the following organizations: Department of Workforce Service (DWS), utilitycompany, my landlord, Bear River Mental Health, Citizens Against Physical & Sexual Abuse(CAPSA), Cache Valley Veterans Association (CVVA), Utah Families Feeding Families, 4 HelpingHearts, and Division of Child and Family Services (DCFS). I understand that the information will remain confidential and is protected by state and federal law, and will only be used for my benefit or tobenefit other members of my household.

Information to be Released: All information concerning my care. Non-identifying information may also be used forthe purposes of research to ensure program success and current and potential funding sources.

Purpose of Release: The purpose of sharing this information is to improve the coordination of services to betterpromote household stability and income.

1) To provide coordinated employment, medical, social, psychological, and other services

2) To evaluate outcomes related to service delivery

3) To improve coordination of services to assist in the household becoming stabilized and improving employment.

Not Required for Services: I understand that authorization is voluntary and that I may refuse to sign thisauthorization. I also understand that refusal to share information with certain organizations may prevent me fromreceiving specific services from certain programs.

Right to Revoke: I understand that my consent will last one year from today’s date unless I revoke my authorizationin writing before that time.

By signing below, I authorize BRAG to share information with other organizations as it relates to myhousehold’s stabilization and employment needs.

This Grievance Procedure is to be followed by program consumers who are dissatisfied with or are denied servicesunder programs funded by Community Service Block Grant (CSBG), Social Service Block Grant (SSBG), and anyother grant or program overseen by the Bear River Human Services Council. Attempts will be made to resolvegrievances as quickly as possible.

Informal: Consumer will bring the issue to attention of the local program provider. If not resolved to consumer’ssatisfaction, the consumer has the option of pursuing the grievance by issuing a formal complaint.

Formal Complaint:

a. Consumers will submit written grievances to local program providers within five (5) working days of the incident or ofknowledge of the incident. The local Program Provider will respond in writing within ten (10) working days. If not resolved to the consumer's satisfaction, they have the option to proceed.

b. If the issue is still not resolved to consumer’s satisfaction, consumers may submit a written grievance within ten (10)working days to the Director of Community Action, Bear River Association of Governments, 170 North Main Street,Logan, Utah 84321. The Director of Community Action will respond in writing within ten (10) working days. If notresolved to consumer’s satisfaction they have the option to proceed.

c. If the issue is still not resolved to consumer’s satisfaction, consumers may submit a written grievance within ten (10)working days to the Executive Director of Bear River Association of Governments, 170 North Main Street, Logan, Utah84321. The Executive Director will utilize support staff or Human Services Council support as deemed necessary toinvestigate information and render a decision regarding the grievance. The Executive Director will respond in writingwithin ten (10) working days. If not resolved to the consumer's satisfaction, they have the option to proceed.

d. If the issue is still not resolved to consumer’s satisfaction, consumers will be provided with address and telephonenumber(s) for the Chairperson of both the Bear River Human Services Council and Bear River Association ofGovernments Steering Committee. A hearing before the Human Services Council will offer the next level of grievanceand help remedy appropriate action(s) regarding the complaint. The nature of the complaint and the investigation shall beproperly documented. The response to the consumer will address the complaint received and relevant action taken. If anymember of the Human Services Council has involvement in the grievance, those members shall exclude themselves fromthe grievance procedure.

e. If the decision is not to the satisfaction of the consumer, the consumer shall be referred to the appropriate stateagency’s grievance procedure. In most instances, this will be the Utah Department of Workforce Services or the UtahDepartment of Human Services.

I understand the BRAG Grievance Procedures Policy and if I have a complaint related to the completionof services that I have received from BRAG, I have the right to file an appeal. This appeal must be madewithin five (5) days from the incident or knowledge of the incident.

Please make appeal to DeannaNewbold, Human Services Director, deannan@brag.utah.gov

Please make sure to provide the following information for the entire household.

Social Security Cards/Permanent Resident Cards – all household members 
Picture ID – all household members over 18 years of age 
Birth Certificate – all household members 
Proof of Income – For the previous month. (ie If application date is July we will need all income received within June)
DWS Benefits Report (Foodstamps, medicaid) - printout available through My Case (if applicable)
 

Once submitting this application please make sure to reach out to our STEPS team to make an appointment to go over it. 435-752-7242