Community Services Department Emergency Housing …Lakes and Pines Application Appeal Process will be provided if you are denied emergency housing assistance (you do not have the right

Page 1 of 16

Community Services Department Emergency Housing Assistance Application

Application Instructions:

[ ] Did you call the Community Services Department and explain your situation? If not, you need to call 1-800-832-6082 option 4. If you did, continue to read and follow the instructions below.

[ ] Collect proof of all the income your household had for the past three (3) months. This includes wages/paystubs, child support payments, disability payments, per capita payments, retirement payments, Social Security payments, General Assistance (GA), Minnesota Family Investment Program (MFIP) or Diversionary Work Program (DWP) payments. If anyone 18 or older did not have income in the past three months they need to provide a statement, signed and dated that they had no income.

[ ] Provide written proof of your household’s current housing emergency. This can be: a letter of past due rent, an eviction or foreclosure notice, a police report, or a third-party signed and dated statement verifying your situation.

[ ] Provide a copy of your lease, rental agreement or mortgage statement. You can get this from your landlord or mortgage company. If you do not have a lease or a rental agreement with your landlord you can ask your landlord to provide you a written statement of your current agreement (what you pay per month, what is included in this amount, and how much you currently owe them).

If you are currently homeless or searching for a new place to live: You will need to provide a copy of the new lease or rental agreement once the new place is found.

[ ] Fill out the attached pages of the application completely. If you need assistance filling out the application, please contact us at 1-800-832-6082 option 4.

[ ] Sign pages 2, 6, 7, 8, 9, 10, 12, and 13 of the application. There must be signatures from all persons over 18 years of age in the household in order for the application to be considered complete.

[ ] Deliver, fax, email or mail completed items to address below. You may want to call us one hour after faxing an application to make sure your application was received.

What happens after you submit your application?

1. Your application is assigned to an Advocate that can best help in your situation.

2. An Advocate will review your application. If your application is incomplete or missing the requested information above, your Advocate will call you and send you an Information Request giving you 14 days to obtain the information and return it to Lakes & Pines.

3. You will be contacted to make a spending plan appointment with a staff person. You must complete this in order to receive financial assistance.

4. Our first goal is to help you make your household and/or family stronger. This means we will offer helpful tips, information and ideas to everyone, but financial assistance will be determined on a case by case basis and will not be available for every applicant. We have various programs that help in various situations, so what works for one family might not work for another. We will also refer your household to other programs, such as the county. Each applicant should be ready and willing to apply for these programs.

Lakes and Pines Application Appeal Process will be provided if you are denied emergency housing assistance (you do not have the right to appeal a denial because Lakes and Pines does not have a program or money in a program to help you) if a resolution isn't successful through the Lakes and Pines Appeal Process, you will be referred to the Community Services Director first, followed by the Executive Director.

1700 Maple Ave East, Mora, MN 55051-1227 Office & TDD • 320-679-1800 • 800-832-6082 • FAX 320-679-4139• www.lakesandpines.org

Reasonable accommodations for people with disabilities upon request. An Equal Opportunity Employer/Contractor Serving the counties of Aitkin, Carlton, Chisago, Isanti, Kanabec, Mille Lacs and Pine

http://www.lakesandpines.org/

MI:

Type of Dwelling: House Mobile Home Townhouse Apartment Duplex

Type of Income

Whose

Income? (Initials)

Whose

Income? (Initials)

$ Unemployment $

Alimony/Child Support $ Workers Comp $

Social Security (Retirement) $ $

$ Retirement/Pension $

$ General Assistance $

$ Other Income $

$ $

Food Assistance

Medical Assistance Employer/Private Pay Number of Persons in your household

VA Medical Services Number of Employed Persons in your HH

Minnesota Care

Is anyone in your household a Lakes & Pines employee or Board member? ( Yes or No)

Lakes & Pines' Community Services Department Emergency Housing Assistance Intake Form

(Please complete all sections with your household information)

SSDI

Disability (Private or VA)

County:Address:

Emergency Phone: ( )Home Phone: ( ) Cell Phone: ( )

Email Address:

Date: Date App Received: Date Housed:

Family Type (Check One)

Female Single Parent

Two Parent Family

Male Single Parent

One Person Household

Lakes and Pines Representative: Date:

Date:

Couple with No Children

Non-Custodial Caregivers

Other

Date:

Client Signature: Client Signature:

Foster Parent

Grandparents with Grandchildren

GROSS ANNUAL HOUSEHOLD INCOME (will be calculated by Advocate)

Other (list)

WIC

Section 8 or other subsidized housing

Migrant Worker (Yes or No)

Non-Cash Benefits (check all household receives) Household Information

Medicare

$

Interested in Head Start (Yes or No)

Anyone in household a veteran (Yes or No)

MFIP/DWP No Income

For Office Use only: New App____ Update____ Program_________________ (Prevention/Homeless) Household No._____________________

Salary/Wages (for all 18 & over)

SSI

MSA

Circle One: Own Rent Other

List All Sources of Household Income for Persons over 18

Homeless In Shelter How long?

Income (Indicate Amount and if (W)eekly, (B)i-

weekly or (M)onthly)

Income (Indicate Amount and if

(W)eekly, (B)i-weekly or

(M)onthly) Type of Income

Township:City, State, Zip:

Last Name: First Name:

Page 2 of 16

First Name

(Legal Name,

no nick names)

Middle

Initial

Date of Birth

(mm/dd/yy)

Relationship to

Head of

Household

Race

Code

Gender

Code

Disability

Code

Education

Code

Convictions

F or M

Hispanic

Yes / No

Veteran

Yes/No

Registered

Voter

Yes / No

U = Unknown

Lakes & Pines' Community Services Department Emergency Housing Assistance Intake Form-Page 1 HOUSEHOLD MEMBER INFORMATION (Refer to Codes at Bottom of Page to complete.)

Status $ Amount

Date:Lakes & Pines Representative:

17 = Unknown

7 = 10th Grade

8 = 11th Grade

9 = 12th Grade, no diploma

10 = High School Diploma

15 = Other Relative

16 = Other Non-Relative

Office Use Only:

14 = 2 or 4 Year degree

HH Member

5 = 7th or 8th Grade

11 = GED

12 = Some Post-Secondary School

6 - 9th Grade

10 = Hearing Impaired

13 = Vo-Tech Certificate

M = Misdemeanor

Convictions

F=Felony

Program

14 = Grandson

13 = Granddaughter

5 = Developmental Disability

6 = Physical/Mobility Limits

1 = Male

2 = Female

3 = Transgender

4 = Does not identify as male,

female or transgender

Date

11 = Other

7 = Physical/Medical

8 = HIV/AIDS

9 = Vision Impaired

0 = No schooling completed

1 = Pre-School

4 = 5th or 6th Grade

4 = Dual Diagnosis

2 = 1st or 2nd Grade

3 = 3rd or 4th Grade

3 = Mental Illness3 = Asian

1 = Alcohol Abuse

2 = Drug Abuse

1 = Black/African American

2 - White

4 = Native Hawaiian or Other Pacific Islander

5 = Native American or Alaskan & White

12 = Grandfather

5 = Daughter

4 = Significant Other

3 = Husband

2 = Wife

1 = Self

11 = Grandmother

10 = Father

9 = Mother

8 = Step-Son

7 = Step-Daughter

6 = Son

Last Name

Continue on additional sheets if more than 6 in household.

Relationship to Head of

Household Education CodesRace Codes

Disability (Diagnosed) Code: Documentation

may be required

Gender Code

Social Security

Number

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Page 4 of 16

Lakes & Pines’ Community Services Department Emergency Housing Assistance Application Health Insurance

Household Member Name

Covered by health

insurance?

Medicaid (MA)

Medicare SCHIP

(MN Care for Children)

VA Medical Services

Employer-provided

COBRA Private Pay MN Care for

Adults

Indian Health

Services Program

Other

1. Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No





6. _____________________

Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

Veteran Status

Did client serve in the United States Armed Forces? (which includes the Army, Navy, Air Force, Marine Corps, and Coast Guard)? (18+ only)

Yes No

Did the client serve on Active Duty, or in the National Guard or Reserves? (18+ only)

No

Yes, Active Duty (regardless of Guard and Reserve answers)

Yes, National Guard

Yes, Reserves

Both Guard and Reserves

If “yes” to questions of either of the above, answer the following questions:

If Guard or Reserve: Was client ever called to Active Duty as a member of the National Guard or as a Reservist?

Yes No

Did client enter Active Duty before 9/7/1980? Yes No

For approximately how many months did client serve? ______________ (# of months) Approximate answers OK

What kind of discharge did client have?

Honorable or under honorable conditions

Other than honorable, but not dishonorable

Dishonorable

Is client receiving VA disability pay?

Yes No

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Housing Status

Extent of homelessness by Minnesota’s definition on the day before program entry:

Not currently homeless

First time homeless AND less than one year without home

Multiple times homeless, but not meeting long-term homeless definition

Long term: homeless at least 1 year OR at least 4 times in the past 3 years

Disability of Long Duration

Does the client have a disability of long duration? (All household members, including children)

Documentation is not required to answer “Yes.” Clients can answer “Yes” even if they have never been officially diagnosed with a disability Alcohol/drug abuse is considered a disability of long duration

Adult Household Member Name Disability of Long Duration?

1. Yes No

2. Yes No

3. Yes No

4. Yes No

5. Yes No

Foster Care

Has the client ever been in foster care? (Youth 24 or younger)

Youth Household Member Name Has been in foster care?

1. Yes No

2. Yes No

3. Yes No

4. Yes No

Last Permanent Residence

Length of Stay in prior residence _______________________________________________________________________________________________________________________________________ How long since last permanent residence_________________________________________________________________________________________________________________________________ State of last permanent address________________________________________________________________________________________________________________________________________ County of last permanent address_______________________________________________________________________________________________________________________________________ City of last permanent residence________________________________________________________________________________________________________________________________________

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Lakes & Pines’ Community Services Department Emergency Housing Assistance Application PERMANENT HOUSING PLAN AND GOALS

Lakes & Pines emergency housing funds are limited and can only be used for housing emergencies to prevent homelessness or reduce a household’s length of homelessness. To help assist you better, please answer the following:

1. Explain in detail what caused your current housing emergency. If you used money normally spent for housing costs to pay other unexpected bills you will need to provide proof of these paid bills along with your application.

2. Please list any issues that might keep you from being approved for a rental unit: criminal history, past unpaid rent, credit problems, etc.?

3. How much can you afford for monthly housing costs. These include rent or mortgage, utilities (heat, electric, sewer/water, garbage, possibly insurance and taxes). Typically, housing costs should be 30% to 50% of monthly take home income.

4. What steps have you taken to solve your housing emergency? Who, besides Lakes & Pines have you asked for

help?

5. We will help you achieve goals to prevent future housing emergencies. What do you think needs to be worked

on? a. b. c.

6. If Lakes and Pines can assist financially, it may be a limited amount. How much can you put towards solving your

emergency? When will these dollars be available?

____________________________________________ Date__________________________________ Applicant Signature ____________________________________________ Date___________________________________ Co-Applicant Signature

Page 7 of 16

General Authorization to Release Information

Printed Name of Applicant Date of Birth Printed Name of Co-Applicant Date of Birth I authorize Lakes and Pines Community Action Council, Inc. to release the following information for coordination of

services:

□ Name □ Address

□ Phone Number □ Rental/Deposit/Utility Amount(s)

□ Income/Benefits □ Current Housing Status

□ Other: __________________________________________________________________________

I (we) authorize the following entities to release and exchange information about me (us) and other household members for the purposes of verification and determining eligibility for program services (please check below). Releases are valid for one (1) year from the date you sign. [ ] Other Lakes and Pines’ departments

[ ] Family Member or Friend : Name:__________________________ Phone:_________________________

[ ] Family Member or Friend : Name:__________________________ Phone:_________________________

[ ] Employer: Name:___________________________ Phone:_________________________

[ ] MN Work Force Center and/or Employment Agencies

[ ] Veterans Services Organization: Name:___________________________ Phone:_________________________

[ ] Credit Reporting Agencies

[ ] Parole/Probation Officer Name: __________________________ Phone:_________________________

[ ] Other: ____________________

[ ] Other: ___________________ _

__________________________________________ ___________________________ Applicant Signature Date __________________________________________ ____________________________ Co-Applicant Signature Date

Lakes & Pines CAC, Inc. 1700 Maple Ave East, Mora, MN 55051-1227

Office & TDD • 320-679-1800 • 800-832-6082 • FAX 320-679-4139 Reasonable accommodations for people with disabilities upon request.

Serving the counties of Aitkin, Carlton, Chisago, Isanti, Kanabec, Mille Lacs and Pine An Equal Opportunity Employer/Contractor

Revised June 2019 Page 8 of 16

Authorization to Release Information to Clinic/Hospital/Other Health Department

I, _______________________________________________________________, ______/______/________, authorize staff (Name) (Birth Date)

of Lakes and Pines Community Action Council, Inc. to obtain information from and disclose information to

the following agencies. The information disclosed or obtained is for the purpose of providing case management

and to coordinate services with local agencies to meet client needs. Releases are valid for one (1) year from the date you sign.

I authorize Lakes and Pines Community Action Council, Inc. to release the following information for

coordination of services (check all that apply):




□ Other: __________________________________________________________________________

Please initial before the agency or provider listed to indicate your agreement.

Initial here _____ ____________________________________________________________________________________

(Name of Clinic/Hospital here)

I understand that my records are protected under State and Federal privacy regulations and cannot be disclosed

without consent unless otherwise provided by law. I understand that I have the right to refuse to supply the

information being requested; however, without this information, the agency/agencies may not be able to

provide me with the service I am requesting. I also understand that I may cancel this consent at any time prior

to the information being released and that in any event, this form expires one year from the date listed below. I

understand that this information will be shared only with the staff or their consultants who need my information

to assist in the administration of their program.

NOTICE TO THIRD PARTIES: Minnesota Statue 15.1611-15.17 allows clients to access certain data recorded

in their files. Be informed that upon request by client or his/her legal representative, this agency may be

required by law to provide access to the information requested by this form.

_______________________________________________ ______________________ Participant Signature Date

_______________________________________________ ____________________ Participant Signature Date


Authorization to Release Information to County Family/Human Service Department or County HRA Office


of Lakes and Pines Community Action Council, Inc. to obtain information from and disclose information to the following

agencies. The information disclosed or obtained is for the purpose of providing case management and to coordinate services

with local agencies to meet client needs. Releases are valid for one (1) year from the date you sign.

I authorize Lakes and Pines Community Action Council, Inc. to release the following information for coordination of

services (check all that apply):




□ Other: __________________________________________________________________________


Initial here _____ Aitkin Carlton Chisago Isanti Kanabec Mille Lacs Pine

(Check which counties you are authorizing information to be released to)














Authorization to Release Information to Landlord, Utility or Mortgage Company


of Lakes and Pines Community Action Council, Inc. to obtain information from and disclose information to the following

agencies. The information disclosed or obtained is for the purpose of providing case management and to coordinate services

with local agencies to meet client needs. Releases are valid for one (1) year from the date you sign.

I authorize Lakes and Pines Community Action Council, Inc. to release the following information for coordination of

services:




□ Other: __________________________________________________________________________


Initial here _____ _____________________________________________________________________________________

(Landlord or Mortgage Company Name here)













Minnesota's HMIS Data Privacy NoticeWe collect personal information about the people we serve in a computer system called Minnesota's HMIS(Homeless Management Information System). Many social service agencies use this computer system,

including street outreach, shelters, and housing programs.

Why do we collect this information?o To help keep this program and others like it going. We are required to use HMIS.

o So we know how many people we serve and the types of people we serve at our agency and in the state

. So we all understand what people need and can plan services to meet these needs.

Who can see information that is in Minnesota's HMIS?. People who work for this agency will use it to help provide services to you or your family.

o Other agencies like this agency that provide services and have received permission from you to see yourinformation. The agencies that participate in Minnesota's HMIS may change from time to time. A copy ofthe current list of participating agencies is available upon request.

. Auditors or funders who have legal rights to review the work of this agency, such as the U.S. Department ofHousing and Urban Development and other state or local government entities.

o Organizations that run, administer, and work on the system, such as the Institute for Community Alliancesor Local System Administrators. When these organizations work on the system, they may see informationabout you.

. People using HMIS information to do research and write repofis, including, but not limited to, the

Minnesota Department of Human Services (DHS). Your personally identifiable information will neverappear in research reports.

. The law says we have to report physical or sexual abuse of children and vulnerable adults. If we think there

is abuse or neglect in your household, we will report it to Child or Adult Protection.

. We may release your information to protectthe health or safety of you or others as required by law.

. Others as required by law, including officials with a valid subpoena, warrant, or court order.

We will not release your information for any other use unless you permit us in writing.

How is your privacy protected?

. All users of data must sign an agreement to protect your privacy and comply with state and federal laws and

policies before seeing any information.

. The computer program used for this purpose has industry standard security protocols and is updated

regularly to meet these security requirements.

What are your rights?. If you do not want your name, social security number, or date of birth entered in HMIS, tell the

intake worker. This agency will not refuse to help you for denying this. However, federal and state

regulations may require limited data collection for funding purposes.

. You have the right to request a copy of the Minnesota's HMIS information about you.

. You have the right to correct mistakes in HMIS information about you.

. lf you think this agency or Minnesota's HMIS violated your privacy rights, you have the right to complainor appeal. Ask a staff person for a complaint and appeal form.

ill i n nc s o t u'.s // I //.1 Dala I'rivacy Nolice & Clienl Release of Information l0-0 l-16

Minnesota's HMIS Release of Information

For:Print First, Middle, and Last Name (Complete one form for each adult) Date of Birth

Your personal information will be collected in Minnesota's HMIS and, with your consent, shared with other

service providers/homeless agencies. If you do not give permission for this agency to share your information, no

other agency in the network will have access to it.

Why share your information?o Sharing reduces the amount of time you have to spend answering basic questions about your situation.

o Sharing allows agencies to focus on meeting your unique needs more quickly.

o Sharing makes it easier for multiple agencies to coordinate housing and services for you and your family.

What information might be shared?

. Family/Household informationo Name, birthdate, Social Security Number. Gender ) race) ethnicity. Reasons for seeking serviceso Living situation and housing history. Services you receive. lf you are homeless or not. Your income and income sources

. Public benefits you receiveo History of domestic violence. Educationalbackground. Employmentinformationo Military history. Health information, including physical

health, HIV, behavioral health

Please check (y') a box:

E Sff,q.nE: I consent to have the information collected about me shared through Minnesota's HMIS with

other partner agencies in order to improve services to me and the services offered to others.

E OO NOT SHARE: I do not want any of the information about me in Minnesota's HMIS shared with any

other service providers/homeless agencies. I understand that not sharing my information may affect the

ability to quickly and appropriately identify services for me.

When you sign this form, it shows that you understand the following.

o We will not deny you help if you do not want us to share your personal information. At the same time,

sharing data does not guarantee that you will receive assistance.

. If you permit us to share your information, this consent is valid until canceled by you.

. If you permit us to share your information, you may change your mind and cancel this consent at any time. Ifyou cancel this consent, your information will no longer be shared from that date forward.

SICNATURE OF CLIENT OR GUARDIAN DATE Signature of agency witness

E Please treat information about my children age l7 or younger the same as mine.

E Verbal Consent obtained by phone (Agency Staff Signature):

Date

Date:

ll4innesola's tl,lllS Dala Privacy Notice & Clienl Release of Information 10-01-16

Page 13 of 16

YOUR PRIVACY RIGHTS: THE TENNESSEN WARNING This sheet tells you about your rights under the Minnesota Government Data Practices Act. This act protects your privacy but also lets us give information about you to others if a law requires it and we tell you before we do it. This sheet tells why and when we will ask for and give information about you. Why do we ask for this information? We may ask you for information so we can:

Tell you from other persons who have the same name or a similar name

Decide if you are eligible to receive services from Lakes and Pines

Assist you in getting medical, mental health, financial or social services from outside agencies

Make reports, do research, audits and evaluate our programs

Advocate for additional services as determined by your needs Do you have to answer the questions we ask? Generally the law does not say you have to give us information; however, without some of the information requested, we may not be able to find the appropriate help for you. Giving us incorrect information or not providing complete information may delay or eliminate some services you would be eligible for. With whom may we share the information we are requesting? The following are examples of agencies or organizations we may need to share information with on your behalf and are not intended to provide a complete list. This does not mean we always share information about you with these people or agencies.

Social Services

Mental health centers

Veterans Services Organizations

Child support workers

Medical facilities

MN Department of Employment & Economic Development

MN Homeless Management Information System

MN Department of Human Services

MN Office of Economic Opportunity

MN Housing Finance Agency

Housing and Urban Development

Community food shelves

Higher education facilities

Court officials

Hearth Connection

Anyone else to whom the law says we must provide information

You have the right to copies of information about you: You may ask if we have any information about you. If we have information about you, you may ask for copies. You may have to pay for these copies. You may give other people written permission to see and have copies of private data about you. If you have any questions about the information, you may ask to have it explained to you. How do you appeal if you think information is not accurate or complete? Your objection must be in writing and must be sent to the Executive Director of Lakes and Pines CAC, Inc. at: Robert Benes, Executive Director Lakes and Pines CAC, Inc. 1700 Maple Avenue E Mora, MN 55051 You may send your own explanation of the facts you disagree with. Your explanation will be attached any time that information is shared with another agency. For more information on how to do this, ask a staff member. If you have any questions about the information on this form, ask a staff person. I have read the above information and understand my rights. Signed:___________________________________________ Date:________________________________

Signed:___________________________________________ Date:________________________________

Page 14 of 16

GENERAL DISCLAIMER

Community Services Department

I understand that:

1. The reason I am being asked for information is to help determine

eligibility for the Program and what other services I may need.

2. Federal and State Laws protect my privacy.

3. Lakes and Pines is asking for private information.

4. I may choose NOT to give this information.

5. If I DO NOT give this information, Lakes and Pines may not be able to show I am

eligible for certain programs.

6. Lakes and Pines is collecting this data to keep records on my family’s participation in

their Programs. This data will be used in applying for future funds.

7. I have the right to see my records at any time, but Lakes and Pines has the right to limit

my review to once every six months.

8. I have the right to see my records more often if I disagree with information in Lakes and

Pines’ records.

9. I have the right to see my records more often if there is new information.

10. I have the right to ask for changes in my records if I find errors.

11. I understand the purpose of the information that Lakes and Pines will keep in its files for

up to five years.

12. Lakes and Pines will give me copies of any record with written request, at my expense.

13. Any information I feel is not correct will be left out until I am sure it is correct.

14. If summary reports are made which include information from my file, the reports will not

identify individuals or families.

15. Lakes and Pines may share information internally within the Lakes and Pines’ agency

departments. I understand the information I provided may be shared with: Other

programs within Lakes and Pines, funding sources.

If you have questions, please contact: Dawn van Hees, Community Services Department Director @ 320-679-1800 ext., 118

Page 15 of 16

Other Services provided by Lakes and Pines

ENERGY – HOUSING DEPARTMENT

Energy Assistance Program

Assists in paying a portion of the household’s home heating bills. This Program can help

people facing utility shut-off or disconnection, needing fuel delivery, or homeowners with

furnace repairs.

Weatherizing your Home

Agency crews and contractors provide energy conservation measures such as

insulation, weather-stripping, and caulking to help reduce energy costs. Furnaces are

also checked. Households should apply for Energy Assistance Program to be

considered for Weatherization services. Priority is given to elderly, handicapped,

families with children, and high-energy consumers.

Housing Rehabilitation Loan

Helps low and moderate income homeowners make basic, permanent repairs to their

home which can also include making improvements for handicap accessibility.

Small Cities Development Program

Helps small communities address area needs (i.e. housing repairs for low-income

homeowners/renters) through a Community Development Block Grant. This program

can only be applied for by cities, townships and counties.

For more information on programs above, please call: (800)832-6082, Option 2

Head Start

Partners with parents to promote school readiness for children ages 0-5 years by

enhancing children’s growth and development in their home and in childcare settings.

Program helps families obtain and connect to health, education, nutritional and social

support services – all at NO COST.

Services are available to pregnant mothers as well.

Options available: Home Base, Center Base, Child Care Partnerships, and Combo

Programs (For more information call the number below)

Call (800)832-6082, option #3

Wages (take home) $

Unemployment $ Housing $

MFIP $ Personal Expenses $

Child Support $ Loans/Credit $

General Assistance $ Vehicle/Transportation $

SSI $

SSDI $

Tribal per capita $

Food Support (EBT) $

Other: $

TOTAL $ TOTAL $

Housing Expenses Personal Expenses

Rent/House Payment $ Food for Household $

Heat $ Eating Out $

Electricity $ Household Supplies $

Telephone/Cell Phone $ Clothing Purchases/Hair Cuts $

Water $ Education-Personal $

Trash $ Education-Children's Activities $

Cable/Internet $ Newspapers/Magazines $

Repairs/Maintenance $ Medical/Dental/Prescriptions $

Homeowners/Rental Insurance $ Laundry $

Property Taxes $ Gifts/Contributions/Dues $

Sub-Total $ Tobacco $

Pet Food/Care/Vet $

Child Support $

Loans/Credit $ Sub-Total $

School $

Personal $ Vehicle/Transportation

Credit Cards $ Car Payment $

Other $ Gas $

Other $ Maintenance/Repairs $

Other $ Licensing/Insurance $

Sub-Total $ Sub-Total $

Page 16 of 16

Monthly Expenses

(Fill in totals from Monthly Expenses)

Monthly Expense SummaryMonthly Income

Lakes & Pines' Community Services Department Emergency Housing Assistance Application

Complete the budget for the household you will be occupying. Not every line may apply to your household.

Co-Applicant Name:

Monthly Budget Summary

Applicant Name:

Documents

Community Services Department Emergency Housing …Lakes and Pines Application Appeal Process will be provided if you are denied emergency housing assistance (you do not have the right