Intake Application for 2024
Provide all income documentation on (taxable and non-taxable) income and all assets to demonstrate a financial need.
Upload as many documents that are applicable:
Current Year Income: Employment Check Stub within last 30 days, SS/SSI Award Letter, VA Benefit Letter, Child Support, TANF, Unemployment, etc.
ID Documents: Birth Certificates for All Household Members, ID/DL for Adults 18 and Over, SS Card for All Household Members, DD214 for any Veterans, Marriage License for Veteran Spouses, Death Certificate for Veteran Surviving Spouse
Current Utility Bills: Electric, Gas, Propane, Water
Texas Department of Housing and Community Affairs
Household Status Verification Form
Systematic Alien Verification for Entitlements (SAVE) System and US Citizenship/ US National
Applicant Certification Form for CEAP, DOE-WAP, LIHEAP-WAP Subrecipients, and SHTF, ESG, HHSP, EH (political subdivision only)
The program for which you are applying requires verification that you are a U.S. Citizen, a non-citizen national, or a legal resident of the United States.
Documentation of your status is required. This agency uses the Systematic Alien Verification for Entitlements (SAVE) System to verify the status of non-citizens.
LIST ALL HOUSEHOLD MEMBERS
Household Member Name
U.S. Citizen or U.S. National
Qualified Alien
This Section for Office Use Only
Documentation Provided for:
Status
Identification
I AM AWARE THAT I AM SUBJECT TO PROSECUTION FOR PROVIDING FALSE OR FRAUDULANT INFORMATION.
Self
Full Name
Relation
Hispanic
Race
Date of Birth
Gender
Education Level Completed
Insurance
Type
Military
Status
Work
Status
Disabled
Self
2
Full Name
Relation
Hispanic
Race
Date of Birth
Gender
Education Level Completed
Insurance
Type
Military
Status
Work
Status
Disabled
3
Full Name
Relation
Hispanic
Race
Date of Birth
Gender
Education Level Completed
Insurance
Type
Military
Status
Work
Status
Disabled
4
Full Name
Relation
Hispanic
Race
Date of Birth
Gender
Education Level Completed
Insurance
Type
Military
Status
Work
Status
Disabled
5
Full Name
Relation
Hispanic
Race
Date of Birth
Gender
Education Level Completed
Insurance
Type
Military
Status
Work
Status
Disabled
6
Full Name
Relation
Hispanic
Race
Date of Birth
Gender
Education Level Completed
Insurance
Type
Military
Status
Work
Status
Disabled
7
Full Name
Relation
Hispanic
Race
Date of Birth
Gender
Education Level Completed
Insurance
Type
Military
Status
Work
Status
Disabled
8
Full Name
Relation
Hispanic
Race
Date of Birth
Gender
Education Level Completed
Insurance
Type
Military
Status
Work
Status
Disabled
9
Full Name
Relation
Hispanic
Race
Date of Birth
Gender
Education Level Completed
Insurance
Type
Military
Status
Work
Status
Disabled
10
Full Name
Relation
Hispanic
Race
Date of Birth
Gender
Education Level Completed
Insurance
Type
Military
Status
Work
Status
Disabled
If renting, name, address, and phone number of landlord:
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I am an applicant of Cornerstone Community Action Agency. I hereby give my permission to release and verify all information requested including employment verification, utility bills and other data needed for program purposes.
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I understand that I may request a hearing to appeal a denial of eligibility.
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I give permission for my comments and picture to be taken for identification purposes, projects, publication, newsletter, and promotional activities for Cornerstone Community Action Agency.
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I give permission for Cornerstone CAA to share my application with other CAA agencies for referral and program assistance purposes.
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The information provided on this application is true and correct to the best of my knowledge. I understand that I may be subject to prosecution for providing false or fraudulent information.
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Are you in need of Basic Needs: Food, Clothing, Food Stamps, WIC, Meals on Wheels, Emergency, Other
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Are you in need of Utility Assistance: Electric, Water, Gas/Propane, Other
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Are you in need of income: SSD, TANF, SS, SSI, VA, Child Support, Budget, Other
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Are you in need of Payee Services: Were you referred by the Social Security office to find a Payee? Do you need assistance with meeting basic needs or paying bills on time?
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Are you seeking Employment: Actively searching for a job, Job Search Assistance, Resume, Other
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Are you in need of Education Services: GED, ESL classes, Vocational/Technical/Certificate Training, etc.
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Are you in need of Veteran Services: Home Repair, Utility Help, Rent/Mortgage, Dental, Transportation Repair/Fuel
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Are you in need of Transportation: To Work, Dr. Appointments, Bus Pass, Other
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Are you in need of Heating/Cooling Assistance: Window Units, Electric Heaters, Gas Heaters, or gas appliances
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Are you in need of Housing Services: Temporary Shelter, Low-Income Housing, Rent Assistance, Weatherization, Repairs
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Are you in need of Child Care/ Elderly Care
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Are you in need of Health Services: Immunizations, Medications, Mental Health Services, Other
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Are you in need of Counseling Services: Family, Alcohol/ Substance Abuse, Other
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Are in need of Legal Services: Child Support, Criminal, Civil, Other
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Are you in need of Case Management Services: Have you registered with Texas Workforce Commission within the last 30 days?
(Declaracion De Ingresos)
For anyone who does not have documentation of income received in the last 30 days
State the gross income for household members, 18 years and older, who have no documentation of the income received in the 30-day period prior to the date of application assistance. (Declarar el ingreso recibido por los miembros de su hogar, que tienen 18 años de edad ó mas, y que no tienen documentación de ingresos por los 30 dias antes del aplicar paraasistencia)
My household has no documented proof of income due to the following situation:
(Mi hogar no tiene prueba para documentar los ingresos por medio de talrazones):
I certify that the above information is true and correct to the best of my knowledge and belief. (Yo certifico que la información proveida de los ingresos es verdadera y correcta según mi saber y creencia.)
I understand that the information will be verified to the extent possible; and that I may be subject to prosecution for providing false or fraudulent information. (Comprendo que la información será verificada hasta donde sea posible y que peudo ser enjuiciado por haber proveido información falsa ó fraudulenta.)
Cornerstone Community Action Agency
Community Services
Optional Form
Persons with Disabilities - Any individual who is:
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A handicap individual as defined in §7(9) of the Rehabilitation Act of 1973;
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§102(7) of the Developmental Disabilities Services and Facilities Construction Act; or§223(d)(1) of the Social Security Act or in §1614(a)(3)(A) or Under a disability as defined in
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Receiving Benefits under 38 U.S.C. Chapter 11 or 15.
APPLICANT'S AUTHORIZATION TO DECLARE DISABLED STATUS:
I hereby authorize for the purpose of confirming my eligibility as a Person with Disability, in accordance with the above-stated definition of Person with Disability.
For ATMOS Clients Only
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 Cornerstone Community Action Agency (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:
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Assessing the needs of low-income, homeless or other special-needs people in order to give better assistance and to improve their current or future situations.
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Improving the quality of care and service for people in need.
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Tracking the effectiveness of community efforts to meet the needs of people who have received assistance.
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Reporting data on an aggregate level that does not identify specific people or their personal information.
I understand that:
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Information I give about my physical or mental health will NOT be shared outside the agency I am working with.
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I have the right to view my MAACLink file with an authorized user.
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Signing this release form does not guarantee that I will receive assistance.
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I may revoke my authorization by completing a revocation form.
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All agencies that use MAACLink will treat my information with respect and in a professional and confidential manner.
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Unauthorized people or organizations cannot gain access to my information without my consent.
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If I receive services from Homeless Prevention Rapid Re-Housing Federal Stimulus (HPRP) Funds, my information may be viewed by other participating agencies across Continuums of Care.
If you Rent your home, the landlord will need to agree to the terms below and sign this form to be eligible for any of the services listed above.
Natural Gas Appliance Consent:
As a representative of Cornerstone Community Action Agency, I have notified the Landlord or Tenant of a residence located at the following address concerning the financial responsibility of enrolling into the Keeping the Warmth program.
ATMOS Energy, the grantor of the Keeping the Warmth program, requires CCAA to obtain monetary investment information from the Landlord or Tenant for the cost of all new gas appliances if the home is a rental property and the tenant does not own the home/property. By signing this form, the Landlord or Tenant for this dwelling has indicated that they fully understand this policy and decided to follow through with the financial responsibility of the appliance listed here.
paid to before work begins.
Heating & Cooling Consent:
Your property is under consideration to receive services from Cornerstone Community Action Agency (CCAA), we administer the CEAP program. The CEAP program under Federal and State rules which have certain requirements of which you, as a landlord, should be aware.
There is NO COST to the landlord or the tenant for Heating/Cooling services. Once the unit is installed or repaired, it will remain the property of the landlord. Cornerstone Community Action Agency (CCAA) is requesting permission to enter your property.
I,
, as Landlord/Authorized Agent for property at,
, have read and understand the above and hereby grant permission for representatives of Cornerstone CAA to enter these premises for the purposes of installing natural gas appliances or new A/C window units, heaters, or to repair the existing window/central unit.
Thank you for submitting an Intake Application. If additional information is needed, someone from Community Services will contact you.
