Bell County H.E.L.PFinancial Assistance

. CenterCrisis Intervention Screening Form

_Fill in all blocks. Put N/A if does not aoolv to household jName: Last. First, Middle & any oilier last name used:

Spouse or Significant other's name:

o P.O. Box)

What is your marital status?Married Single Divorced SeparatedAre you or anyone in your famY N Are you a Vetera

Are you registered withTWC?

Y N

Ely/household associatn or surviving spouse

Is your significantother registeredwith TWC?Y N

ed with the military?jf a veteran? Y N

Have you receivedassistance from Killeenor Temple H.E.L.P.Center Y N

\ l»: I'

s

Date of Birth:

Date of Birth:

Citv:Zip:

SSN:

SSN:

Home:Work:Cell:

Are you and your spouse employed?Full-time Part-timeSelf:Spouse:

Y N ByY N By

Do you normallyearn enough to keepup with your bills?Y N

whom:whom:

Have you applied for assistancerom any other agencies? YVf yes, where?

Please list all people who live in the home include yourself. Start with the oldest to the youngest (Please Print)

NametLast, First, Middle) Relationship Date .ifBirth

Sex Race U.S.CitizenYes No

[.egulAlienYes No

InSchoolYes No

Social Security Number

TYPE OF ASSISTANCE NEEDED:Name of company you need assistance with:

Explain your UNEXPECTED crisis that is preventing you from meeting your financial obligations. Thoroughxplanation required:

Note:

ApprovedDeniedHistory ordered

For Caseworker Only:Electric WaterTransportation

Rent GasPrescription

''I A P P 1

Bell County H.E.L.P. CenterFinancial Assistance Crisis Intervention Screening Form

Monthly Income (+) If an item does not pertain to your household put \Wages-SelfS

Other Household MemberS

Wages- Spouse$

Unemployment

S

Outside assistance (Friends, relative, etc) FromWhom?$

SSl/SSD/V A/RetirementS

Child Support

S

Educational Pell Grant

$

HousingAssistance$Utility Check(HUD)$

TANF$

Food Stamps

$

Total Household Income

$Monthly Expenses (-) If an item does not pertain to your household put N/d|

Rent(what you pay)S

Groceries$Child Care$

Transportation(CarPayment)$

Electric(Extension/Terminat Gasion $$Cable$Child Support$

Gasoline

$

Phone$Loans$

Credit Card

$

Water Total:$ $

Medication Total:$ $Insurance (Car, Life, Health) Total:$ $Other Total:

$$

Please complete ONLY what applies to your request: Pertinent InformationFor utility assistance;

Utility account*: Utility Comoanv: Amount Due:What name is on the account?What period of time does this biHow much can you pay on this t

Name/address of landlord:much of the rent can you pay atIs there and eviction notice? YOn section 8 housing: Y N

Work related items: Work boots

1 cover?)ill?

his time?

Password/Code:Have arrangements been made

Has the deposit bFor Rental Assistance

Phone

with Co. Y Neen paid Y N

Amount due: How

N If yes, date you must be out of residence:If ves. customer amount to oav monthly:

ID cardMedication: Child Care:

Agencv: Self:

Check if request applies to you;

Birth Certificate Health CardOther/Specify

Other/Specify

Referred by

Friend: Relative:

List any other agencies that you have applied with assistance for your bills:

I am in need of assistance listed above and I declare to the best of my knowledge that all of the above informationis true and correct. I do hereby authorize the H.E.L.P Center personnel to release and/or obtain informationconcerning my case to the Local, State, and Federal Government and other interested parties in our service area. Irealize that I may be liable for prosecution or denied services for falsifying the above information.

Printed Name Signature Date

Employment email address.List your last two employers: Start with Present employerIf you have never worked put N/ASelf!

1.Employer Start Date End Date Supervisors name

Work Address Work Telephone Wages

Brief Description Reason for leaving

2.Employer Start Date End Date Supervisors name

Work Address Work Telephone Wages

Brief Description Reason for leavingSpouse/Significant othei

1.Employer Start Date End Date Supervisors name

i 1

Work Address Work Telephone Wages

Brief Description Reason for leaving

2.Employer Start Date End Date Supervisors name

,—, , 1 1

Work Address Work Telephone Wages

Brief Description Reason for leaving

Other household members

1.Employer Start Date End Date Supervisors name

Work Address Work Telephone Wages

Brief Description Reason for leaving

Applicant's additional comments:

Caseworker's notes:

Documents

a I.D. Card

a Spouse I.D. Card

a Food Stamp Printout, TANF award letter

a All Social Security Cards

a Birth Certificates (children)

a Pay Stubs Income: Work, VA, Social Security, Unemployment, Etc.

a Current Bills: Electric, water, cable, phone, car, rent, gas, medical, all expenses

a Current Receipts of bills

a HUD Paperwork

-) Lease

-3 Original electric if helping with electric (must be in clients name)

Comments pertaining to documentation:

rBell County Human Service Killeen201 East Ave. D, Killeen, TX 76541 Ph 254-519-3360 Fax 254-519-3369

AUTHORIZATION TO RELEASE & OBTAIN INFORMATION

_and4

Applicant Spouse

living at .Street Address City State Zip

do hereby authorize persons, organizations, or establishments having information or records concerning

me/us (or) circumstances to furnish such information to a representative of the Bell County Human

Services. I understand that this information wil l be requested only as needed to make an eligibility

determination for my financial assistance request.

I hereby grant permission for the Bell County Human Services to obtain and /or to release information

that may have a bearing on my/our eligibility for family support services or for other human service

agencies, churches, and organizations that I may be referred to. This may include information about

my/our medical status, resource status, income status, and household composition, as well as status of

pending, active or closed applications/cases for other forms of assistance such as: Social Security

Disability, SSI (Supplemental Security Income), Medicaid, TANF (Temporary Aid to Needy Families),

Food Stamps, TRC (Texas Rehabilitation Commission), TCB (Texas Commission for the Blind),

Community Food Banks/Pantries, Salvation Army, St. Vincent de Paul, Section 8/HUD, Housing

Authority, Home & Hope Shelter, FIC (Families In Crisis), Martha's Kitchen, the Bell County Health

District, the MHMR system, Faith Base Organizations, and other community assistance

agencies/programs.

I understand that this release is valid fora period of (2) years from the date of signature unless I revoke it

in wri t ing prior to that date.

Signature Date Signature of Spouse Date

Information Release 01-2010

Bell County H.E.L.P. CenterGuidelines & Rules

Our primary mission is to provide assistance in developing individual plansand/or proper referrals to other agencies to support heads of households inattaining maximum sufficiency for themselves and their families.• ALL clients will be required to attend self-sufficient education classes

PRIOR to receiving financial assistance.• Families that experience a recent layoff, life threatening illness, or

sudden reduction in household income due to unforeseen circumstanceswill have priority.

• In all cases the bills must be in the applicants name and only current bills(within the past 30 days) will be taken into consideration.

• Only one customer from the same household may apply for assistance.• Completion of the application and Orientation does NOT guarantee

assistance will be provided.• Cases approved or disapproved will be at the discretion of the

caseworker.

• **ALL FINANCIAL ASSISTANCE WILL BE BASED ON THEAVAILABILITY OF FUNDS.**

Financial Assistance Programs1. Prescription (no pain medication or chronic illness medication)2 Utilities & Rent

a. NO disconnect and reconnect fees, deposits, down payments,late fees, tampering fees, bounced check fees, transfer fees, andany other miscellaneous fees/penalties.

b. Once utilities are shut off, the account is closed, and/or a clientis evicted from their place of residence, financial assistancecannot be applied to their accounts

3. Transportation (Bus Tokens or Bus Passes)4. Texas State ID's, Driver Licenses, and Birth Certificates.5. Education: GED, Tuition, Books, Licenses, & Certifications.

Ii you have any concerns or complaints about the service you've received regarding your caseyou may coll our main line in Killeen at (254) 519-3360 or send a written complaint to:

Bell Count)' Killeen H.E.LP. Center201 East Avenue D Killeen, TX 76541

Non - Emergency CrisisThe H.E.L.P. Center does not consider the following circumstances anemergency that warrants financial assistance.1. Termination of utility /fuel service due to financial mismanagement or

tampering.2. Eviction notice due to violation of lease to include destruction, poor

maintenance of property, or financial mismanagement.3. Low-income households that receives the three basic assistance services

of HUD or Housing Authority, Food Stamps, and TANF..

4. Loss of Housing Assistance due to non-compliance with HUD orHousing Authority.

5. Refusal or neglect of household to apply for program previously referredto by staff or other agency staff. Must have verification of denial orapproval required, (i.e. referrals to the Free Clinic, Medicaid, FoodStamps, TANF, etc.)

6. Loss of employment due to inappropriate work behaviors, (i.e. Fired,work violations, absentee's or tardiness).

Client Guidelines for Assistance• It takes our staff approximately 3 to 4 business days to process an application.

(This is just an estimate, sometimes it might take longer depending on certaincircumstances).

• ALL documentation is required in order to receive assistance. If you are missingdocumentation at the time of your appointment it is at the discretion of yourassigned caseworker to reschedule or deny your case.

• Children are not allowed in the appointment.• You MUST be on time. If you are late it is at the discretion of your caseworker if

you will be rescheduled an appointment or if your case will be denied.• It is your responsibility to pay for any portion of the bill that we cannot assist

you with. Please make sure that you keep your receipts to show yourcaseworker during your appointment.

The guidelines above have been explained to me and 1 have been given a copy of theseguidelines in Orientation. I understand and agree to follow these guidelines. I also understandthat if 1 do not follow these guidelines or comply with the rules and regulations of the BellCount)' H.E.LP. Center that I might be disqualified or denied from receiving assistance.

Signature Date

Bell County H.E.L.P. Center201 East Ave. D Killeen, TX 76541

Appointment NoticeYou must bring all required documentation in order for your application to be processed. Wewill NOT be able to assist you if you do not have all verification at the time of the appointment.Children are not allowed to attend classes or appointments.

What to bring with you to yourappointment:

Proof of Identity:-Swial Security Cards for all householdmembers.-Valid Texas picture IDs (State IDs or DriverLicense) for all the adults (18+ ) in thehousehold.-Birth Certificates for the children in thehousehold.

Proof of Residence-Copy of your lease-Your lease should include the name,address, and phone number of yourlandlord.- Uhlitv bill for homeowners

Proof of Earned Income or Wages-Bring proof of income for the last 30 days(check stub, copy of checks, letter from youremployer, etc.)-"If Unemployed, must bring in proof ofregistration with TWC.**

Proof of Unearned Income-Award Letters stating monthly benefits tor:TANF, Fixxl Stamp, Social Security, SSI,SSDI, V'A Benefits, Unemployment Benefits,Retirement Pensioa HUD/Section 8, ChildSupport, divorce settlement payments, etc.

Proof of Current Monthly Bills-MUST BRING CURRENT UTILITY BILLS!Receipts, Invoices, Monthly Statements,and/or E-Bill printouts (no screenshots).

"Verification about what has happenedwithin the past 60 days, which has caused

anEMERGENCY OR CRISIS."

Proof of Expenses Causing Loss of Income-Receipts, invoices, pharmacy payments,doctor's bills, divorce decree, emergencyrepair work, bank statements, etc.

Traiga lo siguiente para su cita:

Prueba de Identidad-Trajeta de Seguro Social de todos los miembrosdel hogar.-Valido foto de idenufcacion de Tejas(identifcadores de Estado o Licencia de Conducir)para todos los adultos (18+) en el hogar.-Certificados Je natirruento para los ninos en elhogar.

Prueba de Residencia-Copia de su contrato de arrendarruento-Su contrato de arrendamiento debe incluir elnombre, direccion y numero de telefono de supropetano.-Factura de serviaos publicos para lospropnetarios

Prueba de Ingreso o SalarioTraiga prueba de ingresos para los ultimos 30 dias(talon de cheque, copia de cheques, carta de suempleador, etc.)-** Si no esta trabajando/ debe traer elcomprobante de inscripcion con TWC."

Prueba de Ingresos no Derivados del Trabajo-Premio Cartas indicando prestaciones mensualespor: TANF, Estampillas para Comida, SeguroSocial, SSI, SSDI, beneficios de VA, benehaos deDesempleo, pension de jubilacion, HUD/Seccion8, manutencion de los hijos, pagos de liquidacionde divorcio, etc.

La Prueba de la Actual Facturas Mensuales-DEVE LLEVAR CLIENT AS CORRIENTES DEUTIUDAD!Recibos, facrures, estados de cuenta mensuales,y/o impresos E-Bill (sin capturas de pantalla).

**Verificacion sobre lo que ha sucedido en losultimos 60 dias, lo que ha provocado un de

EMERGENCIA O CRISIS.**

Prueba de Gastos Causando Peridida de IngresosLos red bos, facrures, pagos de farmacia, medicoproyectos de ley, decreto de divorcio, el tiabajo, dereparation de emergencia, estados de cuentabacanos, etc.

OrientationName:

TUESDAY 9:45am - 12:30pmDate:

WEDNESDAY Sam - ll:30amDate:

You MUST stay for the entire Orientation in orderto get an appointment with a caseworker. NOEXCEPTIONS.Be here 10 minutes early. Doors will closepromptly once Orientation begins. If you are lateyou will need to reschedule for the next available

Orientation.Bring the CURRENT bill you are requestingassistance for.No children allowed. NO EXCEPTIONSBring a pen to write with. BLACK ONLY

Bell County Human ServicesH.E.L.P. Center - Killeen