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HOMESAFE PROGRAM APPLICATIONWelcome to the 2020 HomeSafe Program. You are accessing a common application being shared by Neighborworks Blackstone River Valley and the Housing Network of Rhode Island. The HomeSafe program is made possible by funding provided by RI Housing. If you have access to the internet, please use to apply. If you aren’t able to access the online application, please use the enclosed paper application. The HomeSafe program is designed to offer one time financial assistance for households facing a short term emergency with the goal of ensuring households remain housed. Eligible households must demonstrate that they have the resources to remain housed once the HomeSafe funds have been provided. WHO CAN RECEIVE ASSISTANCE: In order to receive assistance under the HomeSafe program, Applicants must have been Rhode Island residents since May 1, 2019 Household income must be at or below 50% Area Median Income. “Household” is defined by the total number of people residing at the address you enter into your application. “Income” is defined as all income sources, regardless of taxable status, for all persons residing in the household. 1 Person2 Person3 Person4 Person5 Person6 Person7 PersonGross Income Cannot Exceed $30,450$34,800$39,150$43,500$47,000$50,500$53,950Residents of Newport, Portsmouth and Middletown use:1 Person2 Person3 Person4 Person5 Person6 Person7 PersonGross Income Cannot Exceed $35,350$40,400$45,450$50,450$54,500$58,550$62,600Residents of Westerly, Hopkinton, and New Shoreham use:1 Person2 Person3 Person4 Person5 Person6 Person7 PersonGross Income Cannot Exceed $31,300$35,800$40,250$44,700$48,300$51,900$55,450WHAT TYPE OF EMERGENCIES QUALIFY AND WHAT TYPE OF ASSISTANCE IS AVAILABLE: If you’ve experienced any of the following short term emergencies, you may be eligible 1) temporary sickness or disability 2) lay off or reduction of income since May 1, 2019 3) Moving from shelter to permanent housing 4) need to move due to domestic violence 5) need to move due to lead paint poisoning of children 6) need to move due to fire or other disaster 7) need to move due to severe code violations or condemnation 8) need to move due to foreclosure or evictionHomeSafe can provide up to $2,000 of assistance to eligible households for 1) past due rent 2) past due mortgage payments 3) late fees incurred on past due rent or mortgage 4) security deposit 5) moving expenses and/or 6) past due utilities.HOW IS ASSISTANCE PROVIDED: If a household is deemed eligible, payments for eligible expenses will be made directly to the creditor, on the applicant’s behalf. Thank you for your interest in the HomeSafe program.CONTACT INFORMATION Applicant Name: _______________________________________________________________Current Address: _______________________________________________________________ _______________________________________________________________Phone Number: (_____)____________________ 4. Can we send you text messages □ YES □ NO related to your application? Email Address: _________________________________________________________________HOMESAFE INFORMATION 6. Have you been a Rhode Island resident since at least May 1, 2019? □ YES Attachment: Please provide of RI residency. You MUST have been a RI resident since at least May 1, 2019 (or be able to provide a Domestic Violence Waiver) to be eligible for this program.*Examples: RI driver’s license, State ID, lease, tax return, or any other document that demonstrates the criteria above.□ NO Do you have a Domestic Violence Waiver? □ YES Attachment: Please provide a copy of your Domestic Waiver □ NO Have you applied to the HomeSafe program through any other organizations? □ YES □ NOHave you received Emergency Housing Assistance Program funds in the past? □ YES □ NOHow did you learn about the HomeSafe program? □ HNRI □ NWBRV □ OTHER__________APPLICANT INFORMATIONDate of Birth ______/_______/__________Social Security No: _______-_____-______________ *this field is optional and leaving it blank will not affect your eligibility Are you or anyone in your household a Veteran? □ YES □ NOAre you or anyone in your household legally disabled? □ YES □ NOGender □ MALE □ FEMALE□ OTHERAre you of Hispanic or Latin origin? □ YES □ NOHow would you describe yourself? □ AMERICAN INDIAN or ALASKA NATIVE□ ASIAN□ BLACK OR AFRICAN AMERICAN□ NATIVE HAWAIIAN or OTHER PACIFIC ISLANDER □ WHITE□ TWO OR MORE RACESHOUSEHOLD COMPOSITION INFORMATION *“Household” is defined as all persons residing at the address you entered at the beginning of this applicationHow many people reside at the address provided above, including yourself? _________Please provide the full names and date of birth for all people in your household Attachment: If you file taxes, please provide a copy of the first page of your most recent tax return____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________HOUSEHOLD INCOME INFORMATION For EVERY member of your household, please provide a copy of the following documents as applicable *You may be asked to provide additional information once a program officer as reviewed your application Most recent paystub for each job held currently or in the last 90 daysSocial Security benefit letterSocial Security Disability benefit letterPension or Retirement Income (IRA, 401K, etc) documentationUnemployment, TDI, Worker’s Comp or TCI benefit letterMost recent bank statement for checking and saving accountsDo you receive child support on behalf of any minor children in the household? □ YES □ NOIf YES, how much per week? ___________Can you provide documentation to support this? □ YES □ NO*Examples: divorce decree, court order for child support, payment history Do you own any rental property? □ YES □ NOAttachment: Please provide a copy of the lease for each unit ownedIf you responded YES to #22, is the mortgage current? □ YES □ NOSHORT TERM EMERGENCY INFORMATIONWhich of the following short term emergencies are you facing? Please select at least one □ TEMPORARY SICKNESS OR DISABILITY □ LOSS OF A JOB OR INCOME IN THE LAST 90 DAYS □ MOVING FROM SHELTER TO PERMANENT HOUSING □ NEED TO MOVE DUE TO DOMESTIC VIOLENCE □ NEED TO MOVE DUE TO HUMAN TRAFFICKING □ NEED TO MOVE DUE TO THREAT OF LEAD PAINT POISONING TO CHILDREN □ NEED TO MOVE DUE TO FIRE OR OTHER DISASTER □ NEED TO MOVE DUE TO SEVERE CODE VIOLATIONS OR CONDEMNATION □ NEED TO MOVE DUE TO FORECLOSURE OR EVICTION Which of the following do you need financial assistance with? Please select at least one □ PAST DUE RENT, AMOUNT DUE _____________ □ PAST DUE MORTAGE, AMOUNT DUE _____________ □ OUTSTANDING LATE FEES ON RENT OR MORTGAGE, AMOUNT DUE _____________ □ SECURITY DEPOSIT, AMOUNT DUE _____________ □ MOVING EXPENSES, AMOUNT NEEDED _____________ □ PAST DUE UTILITIESAMOUNT DUE ELECTRIC _____________AMOUNT DUE OIL _____________AMOUNT DUE GAS _____________AMOUNT DUE WATER _____________AMOUNT DUE SEWER _____________OTHER UTILITY _____________________ AMOUNT DUE _____________*Once you are determined to be eligible, you will be asked to provide documentation supporting the need for financial assistance. Documentation requested will vary depending on your household’s circumstances and may include, but not limited to: copy of current lease, copies of past due bills, demand notice from your landlord, affidavit from your landlord attesting to the amount of past due rent and/or late fees, copy of new lease (for security deposit requests only), invoice from moving company/storage facility (for moving cost requests only), notice of eviction or foreclosure. Additionally, you will be required to provide contact and account information related to your creditor(s).Please briefly describe the short-term emergency you are facing? *this question is optional _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________SUSTAINABILTY INFORMATIONIf you are still working but had your hours reduced, has your employer provided any information about when your hours will return to normal? □ YES □ NOIf you have been laid off, has your employer provided any information about a return to work date? □ YES □ NODo you have a pending unemployment claim? □ YES □ NODate filed _____/_____/_________Are you actively looking for new employment? □ YES □ NODo you have savings that can help you through this short term emergency? □ YES □ NO*Responding yes to this question does not result in an automatic denial. We are simply trying to gauge resources that may be available to sustain your housing over the long term.Do you have access to financial help from any family members? □ YES □ NO*Responding yes to this question does not result in an automatic denial. We are simply trying to gauge resources that may be available to sustain your housing over the long term. DISCLAIMER INFORMATIONI certify that the statements made and information provided in this application are true and correct to the best of my knowledge. (initials) _________I understand that by my submission of this application, I am agreeing to have a program officer review my information for eligibility under the HomeSafe program. I also understand that in no way does this constitute a guarantee of assistance. (initials) _________I hereby authorize my assigned program officer or other agency staff to speak confidentially with any creditor I have identified, on any matter pertaining to my application. (initials) _________I understand that any award made to me under the HomeSafe program will be paid directly to my creditor(s) on my behalf. (initials) _________Applicant Signature _____________________________________ Date: _______________________ To submit this application:In person: You may drop off a completed application and attachments at 1070 Main Street, Suite 304, Pawtucket RI 02860Electronically:You may email a completed application and attachments to info@. Please put “HomeSafe Application” in the subject line. ................
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