1100 NE Vivion Rd., KCMO 64118 816-285-3149 (CCCSF app only)

Updated: 03/20/2020

MLM – Clay County Children’s Services Fund

Assistance Application

Please complete the Enclosed application. Copies of ALL required documents must be

attached to your application. Financial assistance will be provided on a first applied, first

served basis.

Upon completion, please contact Becky Poitras, Development Director, at 816.285.3149, or

beckypoitras@mlmkc.org to schedule an intake appointment (M-F, 1pm-4:30 pm). Documents may

also be emailed or faxed to schedule an appointment.

Eligibility Requirements:

1. Household MUST reside in Clay County, Missouri

2. Household MUST have children age 19 or younger living with them.

Financial Assistance Available:

1. Rent (1 month maximum, current/due or overdue) to help household maintain

housing/prevent eviction

2. Security Deposit & 1st month’s rent to help household move into stable housing

3. Utility payments (gas, water/sewer/trash, electric). Arrears and/or a utility deposit

may be paid to help establish new utility service.

Assistance can be provided for each type of utility and/or rent for each household. Only one

application is necessary, but all documents are required.

Attach the following document copies to your application – these are REQUIRED:

___Picture ID for head of household

___Social Security Cards (or birth certificates) for you and every member of the

household

___Proof of address

___Proof of income (if any) (SSI/SSDI award letter, recent pay stub, child support,

1099)

___Most recent lease agreement (Rent only)

___Letter of eviction, overdue notice, or landlord statement of amount due by month

___Letter of intent to lease to client from landlord, with deposit and rent amounts listed

(Rent only)

___Copy of utility bill(s) or utility deposit statement (Utility only)

___W-9 Form completed & signed by Landlord (Rent only)

1100 NE Vivion Rd., KCMO 64118 816-285-3149 (CCCSF app only)

Updated: 03/20/2020

Household Assistance Application

Before filling out the application, please read and put your initials on the blank line in

front of the statements below.

______I understand that if I leave some answers blank, then I will be less likely to receive

assistance. If I have questions I should complete the application to the best of my ability.

______I understand that all information I provide will be kept confidential.

Name: ____________________________ Date of Birth: __________________________(Must match name on bill or lease)

Social Security#_____________________ Email:________________________________

Address:___________________________________ Zip Code:____________

Phone:_____________________________________ Can you receive texts? Y/N

Number of children (under 18 in the household)_______

Number of adults in the household________

List the names, SSN#s, and date of birth of all individuals in your household:

Name_________________________ SS#_________________ DOB ___________

Name_________________________ SS#_________________ DOB ___________

Name_________________________ SS#_________________ DOB ___________

Name_________________________ SS#_________________ DOB ___________

Name_________________________ SS#_________________ DOB ___________

Office Use Only: Accepted Denied due to: _________________________________________________

If seeking UTILITY assistance, complete the following information:

Choose one: ___Gas ___Electric ___Water

Account #________________Utility: ON OFF (Circle One)

Are you living at the address on the bill? YES NO (CIRCLE ONE)

Required: Call the utility company to find out this current information:

(Speaking with customer service rep will give you different information than is found on

the bill)

Minimum payment required to keep utility on $___________Disconnection Date_________

Last personal (customer) payment amount $____________ Date___________

1100 NE Vivion Rd., KCMO 64118 816-285-3149 (CCCSF app only)

Updated: 03/20/2020

If seeking current/past due RENTAL assistance, complete the following information:

Amount Due per month $_____ Move in date: _________ (month and year)

Past due owed: ___________

(MLM agency will only pay one months rent)

Date of last personal rent payment_________

Amount of last personal payment: $__________

How much can you pay towards the past due amount $_________

Eviction letter? Yes ___ No___ If yes, date of eviction________

If seeking new move-in deposit/rent assistance, complete the following:

Do you need Deposit? Y N (please circle one) Amount $ ________

Do you need first month’s rent? Y N (please circle one) Amount $ ________

For all RENT/DEPOSIT assistance, please complete the Landlord contact information

Landlord Contact Information

Apartment Complex __________________________________________

Contact Name________________________________________________

Phone_______________________________________________________

Email________________________________________________________

Application Certification/Release of Information. This agency may enter the personal information I

have given them into the MAACLink computer system that operates locally inside a secure and

confidential network of agencies by trained representatives. The information I have provided is true and

correct. I understand that my information is electronically tracked in order to assess my household needs

and provide better services such as housing, utility assistance, food and other services. My information

may be shared among the agencies from which I have requested emergency assistance or case

management. If I am applying for utility assistance, my identifying information may be shared with my

utility provider by phone, email, or in written form in order to secure payment to the correct account. If

I am applying for rental assistance, my identifying information may be shared with my landlord or

property management company by phone, email, or in written form in order to secure payment to correct

account.

Applicant’s Signature__________________________________ Date_________________

1100 NE Vivion Rd., KCMO 64118 816-285-3149 (CCCSF app only)

Updated: 03/20/2020

PLEASE HAVE YOUR LANDLORD COMPLETE THIS FORM AND THE W-9

I agree to accept payment from Metro Lutheran Ministry on behalf of tenant_________________________________________________________________________________________, if the application for assistance is approved by MLM.

I have completed, signed, and attached an IRS form W-9 to set up a vendor payment account with Metro Lutheran Ministry. I understand payment cannot be processed until the W-9 has been submitted.

____________________________________ _________________________________ Landlord Authorized Signature Date

Payment will be mailed from the MLM Accounting Department within 20 Business Days from the date of the approval of the request for assistance. This agreement is NOT valid without proper MLM authorized signature.

3031 HOLMES KANSAS CITY, MO 64109 816-285-3149 FAX 816-931-3511

1100 NE Vivion Rd., KCMO 64118 816-285-3149 (CCCSF app only)

Updated: 03/20/2020

CLIENT AND CONSTITUENT RIGHTS STATEMENT

If any client, donor, volunteer, vendor, or other member of the public feels he or she has been treated unfairly by the

agency and the matter cannot be resolved informally through the immediate caseworker or other MLM employee, the

following procedures for managing grievances shall apply. From this point forward donors, volunteers, vendors, and

other members of the public will be referred to in this document as constituents.

STEP 1: The client shall provide a written statement describing the situation to the immediate supervisor of the case

manager. The constituent shall provide a written statement describing the situation to the Executive Director. The

written statement shall be provided as soon as possible but no later than thirty (30) days after the situation in question.

Should the client or constituent need assistance with reading and/or writing a statement, another case manager or

MLM staff member, not named in the grievance, will assist the client or constituent.

STEP 2: The supervisor shall meet with the client no later than five (5) business days following the receipt of the

statement and attempt to provide a solution or explanation in writing within three (3) business days after meeting with

the client, unless additional time is required under the circumstance. The Executive Director shall follow up with the

constituent no later than five (5) business days following the receipt of the statement and attempt to provide a solution

or explanation in writing within three (3) business days after meeting with the constituent, unless additional time is

required under the circumstance.

STEP 3: If the grievance is not resolved to the client's satisfaction at this level, the client shall forward, within five(5)

business days, a copy of the original statement, together with an explanation of previous attempts to resolve the issues,

including the supervisor's written solution or explanation, to the Executive Director. Should the client need assistance

with reading and/or writing a statement, another case manager or MLM staff member will assist the client. If the

grievance is not resolved to the constituent's satisfaction at this level, further steps will be taken involve the Board of

Directors or outside parties to assist in resolving the issue.

STEP 4: The Executive Director shall interview the client, the case manager, and the supervisor within five (5)

business days of receiving the written statement.

STEP 5: The Executive Director shall respond within three (3) business days after meeting with the client, case

manager, and supervisor, with a solution or explanation in writing, unless additional time is require under the

circumstances. The determination of the Executive Director is final.

_____________________________________________________________________________

Client/Constituent Signature Date

_____________________________________________________________________________

MLM Staff Signature Date

Mid America Assistance Coalition- MAACLink KC 4/2016

Client Consent and Release of Information

MAACLink is a computer system that is used locally as a Homeless Management Information System (HMIS). Use of an HMIS is required by the US Department of Housing and Urban Development (HUD) for agencies that receive HUD funding. MAACLink is not electronically connected to HUD and is only used by authorized agencies. All MAACLink users have received confidentiality training and have signed strict agreements to protect clients’ personal information and limit its use appropriately.

A Privacy Notice is available at participating agencies. It provides details on how member agencies and their employees handle client information and data sharing.

I give permission to _____________________________________ (Agency Name) to collect and enter my personal and household information into the MAACLink computer system.

I understand that the MAACLink system is shared with and used by authorized agencies in my community for the purposes of:

1. Assessing the needs of low-income, homeless or other people with special needs in order to give better assistance and toimprove their current or future situations. 2. Improving the quality of care and service for people in need.3. Tracking the effectiveness of community efforts to meet the needs of people who have received assistance.4. Reporting data on an aggregate level that does not identify specific people or their personal information.

I understand that:

• All agencies that use MAACLink will treat my information in a professional and confidentialmanner.

• Signing this release form does not guarantee that I will receive assistance.• My information may be shared with a third party (utility provider, landlord, etc) in order to

process the service I have requested.

• I have the right to a printed copy of my MAACLink file.

• (Optional) Check this box to give consent for your photo to be uploaded to MAACLink.

Client Name (Printed) Client Signature Date

Agency Representative Name (Printed) Agency Representative Signature Date

Agency Representative:

Check this box if you were unable to obtain the client’s signature and verbal consent was given in its place.

Each MAACLink agency will ask you to sign this form at least annually. If after you give consent you decide you no longer would like your information entered into MAACLink, please complete the Client Revocation Form. If you do not revoke this authorization, it will automatically expire on ____________ or one year from the date you sign and date this form.