Community Action Partnership of North Central Missouri 1506 Oklahoma Avenue ~ Trenton, MO 64683

Toll-free Phone: 1-855-290-8544 Toll-free Fax: 1-844-503-1872

www.capncm.org ~ email: contactus@capncm.org

Proof of ALL income for the past 30 days

(current SS award letter or bank statement showing current deposit, pay stubs, etc)

Copy of Social Security cards for everyone in the home

Copy of the bill you need assistance paying (if applicable)

Questions? Call 855-290-8544

Fax 844-503-1872

ext. 1021 or ext. 1023ext 1

H m Fax

CAPNCM COMMUNITY SERVICES APPLICATION

Physical Address: _________________________________________________________ City, St, Zip: ____________________________________________

Mailing Address (if different from above): _____________________________________________________ City, St, Zip: _____________________________

Phone Number: _____________________ Alternate Number: _____________________ Message Phone: Yes or No (Circle One)

Name (First, Middle, Last) SSN DOB M/F Relation Marital Status Race

Health Insurance

Type

Veteran (Y/N)

Highest Education

Level Completed

Disabled (Y/N)

HispanicLatino (Y/N)

self

Attach additional sheets of paper if necessary for listing additional household members. List ALL income sources – wages, self-employment, social security, SSI, child support, TANF, etc. Household Member’s Name Source of Income Amount of Income How Often Received

CAPNCM COMMUNITY SERVICES APPLICATION

In the following questions, please circle the ones that apply to you. Please explain if you select “other”. If it doesn’t apply to you please skip that portion/section.

1) Do you need emergency assistance with any of the following?

Home Repairs Transportation Food Medical Assistance

Shelter Legal Assistance Utilities Cooling Unit

Clothing Not at this time Other ________________________

2) Which of the following is true of your family’s income?

Income meets needs and allows for some unexpected expenses

Income meets basic needs, but not prepared for crisis

Not enough income to meet basic needs

No income

3) Is any person in the household paying child support?

Yes No If yes, how much? __________________ 4) Is any person in the household ordered to RECEIVE child support? Child Support Case Number:

Yes No If yes, how much? __________________ _________________________ 5) How does your family manage money?

Keeps records of expenses Has checking account Uses cash to pay bills

Has savings account Uses money orders to pay bills

Other ___________________________________________________________

6) What past due bills does your family have?

Utilities Housing Telephone Payday/Title Loans

Trash Credit Debts Water/Sewer None at this time

Other ___________________________________________________________

7) Does your family have credit debts?

No credit debt Credit Cards Bank Loans Rent-to-Own

Medical/Hospital Bills Payday/Title Loans Other: _________________________

Revised 09-2013

CAPNCM COMMUNITY SERVICES APPLICATION

8) In the past 6 months, has your family done any of the following to meet basic needs?

Had to choose between necessities Borrow from friends &/or relatives Use bank loan

Use payday loan Use car loan Use pawn shops

Other: ______________________________________________________ None

9) How did you prepare your last income tax return?

Paid tax preparer Volunteer tax preparer Filed own taxes

Did not file, but should have Had no income on which to file taxes

10) Did your family receive Property Tax Credit (PTC) or Credit for Rent Paid (CRP) last year?

Yes No N/A

11) Did your family receive the Earned Income Tax Credit (EITC) last year?

Yes No N/A 12) Has family’s TANF, Medicaid, or Food Stamps been sanctioned in the last year?

Yes No N/A 13) Are you interested in budgeting &/or financial education training?

Yes No 14) Do you rent or own? ___________ Monthly amount your family pays for housing (whole $ amount): _________ 15) Do you have any of the following housing problems?

No, I don’t have any housing problems High housing costs High utility costs

Major Repairs Needed Overcrowded Unsafe/No electricity

Poor Plumbing Minor Repair No stove/refrigerator

No air conditioning Homeless

16) Does your home have the appropriate number of bedrooms for your family size?

Yes No Homeless Shelter 17) Does your family have subsidized housing (HUD)?

On waiting list Yes No N/A 18) Would you be interested in owning your own home? Yes No

CAPNCM COMMUNITY SERVICES APPLICATION

19) Is your home weatherized?

Does not need weatherization Weatherization needed Have applied – on list

Has been weatherized by CAPNCM Has been weatherized by non-CAA

20) What is your primary source of heat?

Electric Natural Gas Fuel Oil Wood Propane Other: ____________________ Average cost of heat each month: ____________________ Average cost of cooling each month: __________________ 21) Does your family have any of the following barriers to obtaining and preparing nutritious meals?

No barriers Not enough time Inadequate or lack of equipment to cook/store food

Special diet needs Inadequate or lack of transportation

Lack of experience/knowledge in meal planning/preparation

22) Is your family’s food supply adequate?

Always Sometimes Seldom Never 23) Does your family need WIC?

Yes No Currently Receives 24) Does your family need Senior Meals?

Neither Home Delivered Congregate 25) Does anyone in your family need family planning services?

Yes No Currently Receives 26) Does anyone in your household need prenatal care?

Yes No Currently Receives 27) Does your family have trouble meeting health needs due to lack of transportation?

Yes No

28) Does your family currently receive food stamps?

Yes No Applied/Waiting Denied

CAPNCM COMMUNITY SERVICES APPLICATION

Do either of the following keep you, or anyone in the household, from obtaining medical care? Co-pays & deductions for medical care Co-pays on prescriptions Neither If so, who? ___________________________________________ Overall Health (Please complete for each adult in the home.)

Name (List ALL adults)

Overall Health (Good / Temporary / Chronic Problem) What is your condition or disability? Do you require any of the following?

Home Chore Worker / Hospice / In-Home Health Worker / Etc.

Do you need any of the following? (Mark the services needed with a X or √. Mark none if nothing is needed.)

Name (List all adults and complete) Immunization Medical

Services Dental

Services Vision

Services Prescriptions Drug/Alcohol Counseling

Mental Health

Services None Other (Explain)

CAPNCM COMMUNITY SERVICES APPLICATION

Current Household Employment Situation Name Name Name Name Name

Name (List all adults)

Employment Status (Working / Not Working)

Condition of Unemployment 1. Unemployed, less than 3 months; 2. Unemployed, 3 months or more; 3. Unemployed, full time homemaker; 4. Unemployed, never worked; 5. Age 14-25 in school and not working; 6. Adult full time student; 7. Retired; 8. Disabled; 9. Other

Do you want to improve your work situation? (Y/N)

If you could improve your work situation, on which items would you focus? 1. Location of job; 2. Better working conditions/environment; 3. Better pay; 4. Increase benefits; 5. More flexible working hours; 6. More hours; 7. More job stability; 8. Change career or position; 9. Increase responsibility; 10. Reduce required overtime

What are your strong points in looking for work? 1. Formally trained or certified skills; 2. Skills gained from experience; 3. Positive work history; 4. Dependable transportation; 5. Education; 6. Dependable childcare

Do you have now, or are you concerned about any of the following? 1. Emotionally unable to work; 2. Lack of adequate, reliable transportation; 3. Pregnancy; 4. Lack of adequate or reliable childcare; 5. Lack of language skills; 6. Permanent health/disability problem; 7. Adult dependent care; 8. Temporary health problem; 9. Lack of high school diploma or GED; 10. Discrimination – age, race, gender, etc; 11. None of these

Do you need, or are you registered, with any of the following? 1. Shelter workshops; 2. Skills building; 3. Job seeking – resume writing, job applications, interviewing skills; 4. Business ownership; 5. Vocational rehabilitation; 6. Career search – Great Hires or similar service; 7. Missouri Career Center/WIA; 8. None of these

Would you like one-on-one support achieving work goals?

Are you satisfied with your educational attainment? Yes No If no, whom in the household would like to improve their education? _______________________________ Current Household Education Situation Name Name Name Name Name

Name (List everyone in household)

If you could improve your education, what things would you focus on? 1. Improve writing skills; 2. Obtain a GED; 3. Improve language skills or English skills; 4. Improve math skills; 5. Get training in a specific skill area; 6. Earn a 2-4 year degree; 7. Improve reading skills

What are your strong points in seeking further education? 1. Has support for the effort, including family; 2. Has specific education goals; 3. Dependable transportation; 4. Dependable childcare

Do you need one-on-one literacy/reading tutoring?

Do you have, or are you concerned about any of the following barriers to your current or future educational plans? 1. Transportation; 2. Childcare; 3. Previous difficulty in school; 4. Cost of school; 5. Lack of support or resistance from family members; 6. Language issues; 7. Discrimination; 8. Lack of high school diploma or GED; 9. Health issues

Would you like any of the following? 1. Missouri Career Center/WIA; 2. Pell grants or other financial aid; 3. Specialized skills training; 4. Community College/University; 5. Vocational Rehabilitation; 6. ABE/GED classes; 7. One-on-one support in achieving educational goals

_______________________________________ X_____________________________________ _____________________ Head of Household Printed Name Head of Household Signature Date _______________________________________ _______________________________________ _____________________ Staff Printed Name Staff Signature Date

Rev. 9/10/12

C Child Information (Please fill out completely for each child under 18 in the home.) Child’s Name

Both parents currently reside in home? (Y/N)

Current child support situation? (Receive regularly, Irregularly, Need to apply, N/A)

Child regularly eats breakfast?

Child receives free/reduced lunch at school?

Child needs supplemental food in the summer?

Child needs Head Start?

Child needs one-on-one literacy / reading or English as a 2nd Language tutoring?

State of child’s overall health? (Good / Temporary Condition / Chronic Condition)

If child has medical condition(s), please list

Does anything keep you from obtaining medical care for this child?

Additional health issues?

This child needs the following (please mark using an X in the appropriate box if applicable):

Immunizations

Medical Services

Dental Services

Vision Services

Drug/Alcohol Counseling

Mental Health Services

Prescription Medications

None of the Above X____________________________________________________ _______________________________________ Parent Signature Date _____________________________________________________ _______________________________________ Staff Signature Date

CAPNCM COMMUNITY SERVICES APPLICATION

Household Comments:

Individual Comments:

CLIENT CONFIDENTIALITY AGREEMENT / RELEASE OF INFORMATION I certify that the information given on this application is true and accurate to the best of my knowledge and belief. I understand that such information is subject to verification and I further realize that falsified or fraudulent information may result in the rejections of this application. Under the terms of this Agreement, CLIENT agrees to release to CAPNCM information that is confidential and proprietary to CLIENT (- Confidential Information), to be used solely or the Agency’s related statistics, services, and programs. – Confidential Information refers to any and all information of a confidential, proprietary, or secret nature which is or may be related in any way to the family, medical records, job history, present or future, or CLIENT, or any related data. Confidential Information included, for example, but not limited to: spouses or other family members, ages, salaries, financial standings, criminal records, medical records, and all other pertaining to the family information. CAPNCM will consider all information received from CLIENT to be strictly confidential, as required by the Privacy Act, and subject to the restrictions of this Agreement; except for information that is: (i) generally known to the public, (ii) in the possession of CAPNCM before receipt from CLIENT, (iii) obtained later by the Agency from a third party without restriction or violation of Agreements. CAPNCM will not disclose CLIENT’s Confidential Information to any other party without the prior written consent of CLIENT, CAPNCM may, however, disclose Confidential Information to its employees and/or programs but only if the employee has a legitimate need to know and has agreed to terms similar to those in this Agreement. Community Action Agency may also disclose this Confidential Information (i) to medical personnel in an emergency; (ii) to qualified personnel for research, audits, or program evaluation, as long a CLIENT identities are not identified; (iii) to a third party based on court orders; and (iv) to appropriate authorities in cases of suspected child abuse or neglect. CAPNCM will be responsible for any use or disclosure of Confidential Information by any of its employees or agents to third parties who should not share this information. This agreement may be amended only in writing and shall be governed by the laws of the State of Missouri. Please sign below to indicate that you have read this Consent and agree with its terms. Client Signature: X_______________________________________ Date: ________________________

Interviewer’s Signature: ___________________________________ Date: ________________________

CAPNCM COMMUNITY SERVICES APPLICATION

MISSOURI COMMUNITY ACTION MANAGEMENT INFORMATION SYSTEM

Client Consent – Release of Information

The Missouri Community Action Management Information System (MIS) serves Missouri’s Community Action Agencies, a network of partner agencies working together to provide service to low-income individuals and families in Missouri. The information that is collected in the (MIS) database is protected by limiting access to the database and by limiting with whom the information may be shared, in compliance with the standards set forth in the Health Insurance Portability and Accountability Act (HIPAA). Every person and agency that is authorized to read or enter information into the databases has signed an agreement to maintain the security and confidentiality of the information. Any person or agency that is found to violate their agreement may have their access rights terminated and may be subject to further penalties. BY SIGNING THIS FORM, I AUTHORIZE THE FOLLOWING: I authorize the partner agencies and their representatives to share the following information regarding my family/household and me. I understand that this information is for the purpose of assessing our needs for employment, housing, utility assistance, food, counseling and/or other services. The information may consist of the following:

• My financial situation, to include the amount of my income, and savings of money and/or food stamps I may have. • This information may also include debts I owe for utilities, rent, etc. • Indentifying and/or historical information regarding myself and members of my family/household.

I UNDERSTAND THAT:

• Information I give concerning physical or mental health problems will not be shared with other partner agencies in any way that identifies me.

• The partner agencies have signed agreements to treat my information in a professional and confidential manner. I have the right to view the client confidentiality policies used by the MIS.

• Staff members of the partner agencies who will see my information have signed agreements to maintain confidentiality regarding my information.

• I have the right to request information about who has accessed my information. • The partner agencies may share non-identifying information about the people they serve with other parities working to end

poverty. • The release of my information for the MIS does not guarantee that I will receive assistance, and my refusal to authorize the

use of my identifying information does not disqualify me from receiving assistance. • This authorization will remain in effect unless I revoke it in writing, and I may revoke authorization at any time by signing a

written statement available at any partner agency. • If I revoke my authorization all identifying information already in the database will remain, but will no longer be shared with

partner agencies. Partner Agencies: A list of the partner agencies within the Statewide Community Action Network may be viewed prior to signing this form.

_________________________________________ X________________________________________ _____________________ Client Name (please print) Client Signature Date _________________________________________ Social Security Number _________________________________________ _________________________________________ _____________________ Agency Personnel Name (please print) Agency Personnel Signature Date This form may not be amended except by the MIS Steering Committee. 6/6/05

Community Action Partnership of North Central Missouri 1506 Oklahoma Avenue ~ Trenton, MO 64683

Phone: 660/359-6863 or 660/359-3907 ~ Toll Free 1-855-290-8544 ~ Fax: 660/ 359-6619 Community Services Representative ~ Ext.1021 & 1023

DATE: ____________ COUNTY:___________ NUMBER IN HOUSEHOLD: ________ ____________________________ Date of Birth__________ ____________________________________ Head of Household Address ____________________________ Date of Birth__________ ____________________________________ Person making application City State Zip Code _____________________________________________________________________________________________ (Name(s) of additional family members) _________________________ _____________________________ _____________X 12= _____________ Telephone Number Source of Income Monthly Amount Annual Amount BRIEFLY EXPLAIN THE EMERGENCY:_________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Amount needed $ ____________________ ______________________________________________________________________________________________ Vendor Name and Address Second amount needed if applicable: $___________ _______________________________________________________________________________________________ (Vendor #2 Name and Address)

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I certify that the above information is true and complete and I release from liability any representative of CAPNCMin securing verification and information pertaining to this request.I verify that I have not obtained other assistance for this emergency unless I have specified this. _________________________________ _____________ _________________________________ Client’s signature Date Employee’s signature

######################################################################################## Date Paid __________ TO WHOM:_________________________ Amount $________ Check #___________ Date Paid __________ TO WHOM: _________________________ Amount $________ Check# ___________ FUNDING SOURCE USED: _____________________________________________________________________________ FUNDING SOURCE USED:______________________________________________________________________________

AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER / SERVICES PROVIDED ON A NON-DISCRIMINATORY BASIS

CSBG Zero Income Determination

Name: ___________________________________________ Date: ____________________ Address: _____________________________________________________________________ City: ____________________________________ State: ______________ Zip: ____________ Please help us to understand how you have been managing with little to no income by answering each of the following questions:

1) When did you last receive money? Who was it from and how much was it? ____________________________________________________________________________________ 2) Do you have savings or other resources? Yes No If yes, where are these resources located and what is their approximate value? ____________________________________________________________________________________ 3) Do you receive money from relatives or friends? Yes No If yes, how often is this received, how much is received, and from whom? ____________________________________________________________________________________ 4) Do you work odd jobs? Yes No If yes, what is the job, how much are you paid, and when were you last paid? ____________________________________________________________________________________ 5) How have the rent/house payment & utilities (gas, electric, water, etc) been paid for the last three months? ____________________________________________________________________________________ 6) Have you applied for food stamps? Yes No If no, why not? ____________________________________________________________________________________ 7) How do you pay for food and transportation expenses? ____________________________________________________________________________________

I/We certify this information given to CAPNCM where I am applying for assistance is correct to the best

of my knowledge. __________________________________________ __________________________________________ Name Spouse/Other Adult __________________________________________ Staff Signature