EOAC - Economic Opportunities Advancement Corporation

EOAC
Community Programming
500 Franklin
Waco, TX 76701
254-756-0954
THIS IS NOT AN ENTITLEMENT PROGRAM.
Applications will NOT be processed unless All information is provided by client. Please pay close
attention to the list of required documents below. Incomplete information will result in loss of your
place in the processing. No mailing, drop off, faxing, or E-mailing of ANY PAPERWORK.

Income for the last 30 days if applicable to your entire household:
All income must be dated within the last 30 (thirty) days from day of interview (including income
for date of interview). Award letters must show 2015 benefits.
___ Employment Check Stubs
___ Social Security Award Letter
___ Child support printout
___ Disability Award Letter
___ TANF/Food Stamp Award Letter ___ Pension Letter
___ Retirement Letter
___ Unemployment Printout
___ Workers Comp. Letter
___ Veterans Award Letter
____ Self Employment form
____Teachers Retirement Letter
___ Declaration of Income with notarized form
___ Housing Utility Assistance Check stub
___ Student Financial Aid Printout
___ All Other Household Income

___ Social Security Number and Date of Birth for Everyone in the Household.

___ 12 MONTH or however long you have been with your Utilities Company billing history for
your gas, electric and propane utility bills. (This can be obtained from your electric, propane or gas
company.)
___ Electric
___ Gas
___Propane

Utility Bill - Must provide a copy of each bill even if not requesting payment.
___ Current Electric Bill
___ Current Gas bill ___ Current Propane bill

Complete attached Application packet and LEAVE NO BLANKS before interview.
 We are unable to assist with Pay-As-You-Go or Prepaid Utilities.
All financial assistance is made based upon Federal Guidelines and Regulations of Poverty and
Documentation Need. All assistance is subject to the Availability of Funds. Funding is not guaranteed.
Clients are responsible to pay their portion of the bills and any/all fees/deposits occurred.
Revised 1.5.15
EOAC Community Program Utility Assistance
Comprehensive Energy Assistance Program (CEAP)
General CEAP Assistance:
1. Must be within 125% of poverty level. (Gross income)
2. Only 1 bill may be submitted within the month
3. Must be living in the home for which you are applying for assistance.
4. Applications are good for one calendar year (Jan through Dec).
5. Utility company must have a vendor agreement with us.
6. If the vendor that you use does not have an agreement with us, you may request that the Director of Community
Programming send the forms to the vendor for approval.
7. Client must provide the previous 30 days proof of income including the date of the interview for all household members. (No
bank statements or HHSC award letter will be accepted.)
8. If anyone in the household has no income: the Statement of no Documented Proof of Income needs to be notarized before
the interview; and they must register for employment with Work in Texas (TWC) at www.workintexas.com.
9. If utilities are completely shut off you, will need to contact your utility company to determine if there are fees or deposit due.
(EOAC cannot pay fees or deposits on accounts)
10. Utility account must be active and not a closed account in order to receive assistance.
11. Must provide a copy of each bill even if not requesting payment. Current Electric Bill, Current Gas bill/Propane bill.
12. EOAC does not make extensions on utility bills.
13. We are limited to the funding that is provided to us by the Texas Department of Housing and Community Affairs (TDHCA).
14. We have two funding programs that we can assist clients from with a maximum amount for each:
Household Crisis Program-AS long as funding is available
 Eligible amounts range from $1,000 to $1,200 per calendar year. (EOAC cannot guarantee all payments if funds are
exhausted.)
 Client is in a crisis situation (Utility cut off)
 Disconnection notice (Limited to 2 per year)
 Under Weather Related Crisis - during the usage cycle - three or more days: 95 degrees or higher for the cooling season and
32 degrees or lower for the heating season.
 Must have the current utility bill (if applicable).
Utility Assistance Program-AS long as funding is available
 Eligible amounts range from $1,000 to $1,200 with 6 or 8 payments per calendar year.
 We ask that the client bring in a 12 month Billing History (or for the length of time they have been with their utility
company) at the time of their first visit.
 If they have been with the utility company for 12 months we can assist you based on the usage cost (payment minus deposit
and fees) from last year’s Billing History for future payments. No future appointments needed.
 You will not be eligible for any additional payments during the months that payments are set up for you during the year.
(Payments based on last year usage and not this year’s bill)
 If you have not been with the utility company for 12 months you will have to bring your current bill each month for your
future payments
EOAC has the right to change or amend information listed.
All financial assistance is made based upon Federal Guidelines and Regulations of Poverty and Documentation Need. All
assistance is subject to the availability of Funds. Funding is not guaranteed. Clients are responsible to pay their portion of bills
and any/all fees/deposits occurred.
I have read and understand the above information.
__________________________________________
Signature of Client
______________________________
Date
Revised 1.5.15
EOAC COMMUNITY PROGRAMMING CLIENT INTAKE
Client File # ______________________
Part I
Name:
County:
(First)
(Last)
(M.I.)
Residence Address:
(Street)
(apt. #)
(City)
(Zip)
(Street)
(apt. #)
(City)
(Zip)
Mailing Address:
Phone #/Email
(Home)
(Work)
(Cell)
(E-Mail)
Part II
Give the following information about each household member, including yourself.
Name
Date of Birth
Sex
SSN
1
RaceHeath
EducationWhite/Black/
Insurance Highest
Asian/Indian/ Hispanic Disabled Veteran
or
Grade
MuliRace/
Medicaid completed
Other
EOAC COMMUNITY PROGRAMMING CLIENT INTAKE
Part III
List all income for household members.
Source of Household Income for Previous 30 days (including income for the date of interview)
Name
Name
Name
Name
Name
Alimony
$
$
$
$
$
Child Support
$
$
$
$
$
Dividends/rental Income
$
$
$
$
$
Employment/Wages
$
$
$
$
$
Food Stamps
$
$
$
$
$
Student Financial Aid
$
$
$
$
$
Private Pensions
$
$
$
$
$
Teachers Retirement
$
$
$
$
$
Regular Insurance/annuity payments
$
$
$
$
$
Retirement Benefits
$
$
$
$
$
Social Security
$
$
$
$
$
Social Sec Disability Income (SSDI)
$
$
$
$
$
Supplemental Social Security (SSI)
$
$
$
$
$
TANF
$
$
$
$
$
Self Employment
$
$
$
$
$
Unemployment Compensation
$
$
$
$
$
Veteran's Benefits
$
$
$
$
$
Workman's Compensation
$
$
$
$
$
Other: (explain)
$
$
$
$
$
No Income
$
$
$
$
$
IV
Is anyone in the household an EOAC Employee or EOAC Board Member?
_____Yes
_____ No
If yes, a signed letter from EOAC Executive Director must accompany application prior to service being given.
2
EOAC COMMUNITY PROGRAMMING CLIENT INTAKE
V
Complete the following information for your household
Check One:
Household Type:
Other Characteristics
Single Parent/Female
Farmer
Single Parent/Male
Migrant Farmer
Two-Parent Household
Seasonal Farmer
Check One:
Single Person
Two Adults-No Children
Other
Housing
Monthly Amount
Own Home
$
Rent Home
$
Homeless
$
1
Public Housing
$
2
Section 8 Housing
$
Household Size
Check One:
3
4
5
6
7
8 or More
Information on Landlord:
Name:
Address
City/State/Zip
Phone Number
Has your home been Weatherized by EOAC Weatherization Program?
______Yes
When:_____________
______No
3
EOAC COMMUNITY PROGRAMMING CLIENT INTAKE
VI
Check
How does the family pay for heating and Cooling? One:
What is the main way you heat your home?
To Utility Company
Space Heater
To Landlord/Manager
Wall Furnace
Included in Rent
Electric Heater
Fireplace
What is the main way you cool your home?
Cook Stove
Check
One:
Wood Burning Stove
Central Unit
Central Heat
Window Units
Other
Evaporative Cooler
None
None
All Utility Providers and Account Numbers for the Household must be listed. (Include even if assistance is not required at interview)
Indicate "N/A" if Utility is not used in your home.
Name of Vendor
Electric Service Provider:
______Heat
Account Number
______Cool
Name of Vendor
______Heat
Natural Gas Provider:
Account Number
______Cool
Name of Vendor
Propane Company Provider:
______Heat
Account Number
______Cool
Future assistance cannot be provided for any utility account that is not listed at the time of interview
Part VII
CERTIFCATION (APPLICANTS MUST SIGN THIS SECTION)
I certify that the information provided on this application is true and correct to the best of my knowledge and belief. I understand that any
falsification could result in my case closed and request for repayment.
(Applicant Signature)
(Date)
4
EOAC COMMUNITY PROGRAMMING
NEEDS ASSESSMENT
SERVICE
SERVICE NEEDED
YES
NO
Comments
Basic Needs:
Food, Clothing, Food Stamps, WIC, Meals
on Wheels, etc.
Income (Government Assistance):
RSDI, TANF, SS, SSI, VA, Wages, other
Transportation:
To work, Doctor appointment, other
Utility Assistance:
Gas, Propane, Water, Electric, other
Heating/Cooling:
Appliances:
None in house, not working properly, other
Housing Needs:
Temporary Shelter, Low income housing,
Rent assistance, Weatherization, Repairs,
other
Child Care, Elderly Care, other
Education:
GED, English as a Second Language,
Vocation/Tech training, other
Employment:
Looking for a job, job search assistance,
resume, other
Veterans Needs:
Medical, Training, other
Legal Needs:
Child Support, Criminal, Civil, other
Health Needs:
Immunizations, Medication, Mental Health
Services, other
Counseling:
Family, Alcohol/Substance Abuse, other
Other needs not identified on this
assessment
*Client needs to fill out BEFORE interview for Caseworker to identify the needs of the household. Information is
voluntary and confidential.
Client Signature: _______________________________________
5
EOAC
COMMUNITY PROGRAMMING
RELEASE OF INFORMATION
Client Name: _________________________________________
I give permission to EOAC to share any information necessary with
other individuals or organizations in order to provide case management
services and secure resources on my behalf. I understand that
information will only be shared when necessary to meet the
requirements established by the program. I authorize EOAC to share my
educational, services received information, and employment records
with individuals and organizations as needed.
Signed: _______________________________________________ Date: ___________________
6
Revised 1.5.15
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.
EOAC
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 special-needs people in
order to give better assistance and to improve 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:
· Information I give about my physical or mental health will NOT be shared outside
the agency I am working with.
· I have the right to view my MAACLink file with an authorized user.
· Signing this release form does not guarantee that I will receive assistance.
· I may revoke my authorization by completing a revocation form.
· All agencies that use MAACLink will treat my information with respect and in a professional and confidential manner.
· Unauthorized people or organizations cannot gain access to my information without
my consent.
· 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.
Client Name (Printed)
Client Signature
Date
Agency Representative Name (Printed)
Agency Representative Signature
Date
7
EOAC
Budget Counseling Worksheet
Client Name:____________________________
INCOME-Last 30 Days-Including date of inteview
Enter $Dollar Amount
Employment:
Social Security:
SSI:
SSDI:
TANF/Food Stamps:
Retirement:
Veterans:
Student Financial Aid
Pension:
Unemployment:
Self Employment
Child Support:
$
$
$
$
$
$
$
$
$
$
$
$
Workers Compensation
Teachers Retirement:
Housing Utility Assistance:
Insurance/Annuity:
Alimony:
Dividends/rental income:
Other:
TOTAL INCOME:
$
$
$
$
$
$
$
$
EXPENSES-Last 30 Days
Enter $Dollar Amount
NECESSARY EXPENSES:
Food:
$
Rent/Mortgage:
$
Electricity:
$
Gas:
$
Water:
$
Child Care:
$
Telephone:
$
Savings:
$
Trash:
$
Clothing, Diapers:
$
Laundry, Dry Cleaning:
$
Medical, Dental:
$
Hair cuts:
$
Taxes:
$
Insurance (Life, medical, rent): $
Other:
$
TRANSPORTATION
Bus Fare:
$
Car Payment:
$
Gasoline:
$
Vehicle Insurance:
$
Repairs, License, etc.
$
OTHER EXPENSES
Church Donations:
$
Cable TV/Internet:
$
Cigarettes, Tobacco:
$
Beverages, Snacks:
$
Eating Out:
$
Entertainment:
$
TOTAL EXPENSES
$
TOTAL INCOME: $
TOTAL EXPENSES: $
TOTAL SPENDING MONEY: $
8
Revised 1.5.15
Economic Opportunities Advancement Corporation
Community Program
500 Franklin Ave
Waco, TX 76701
(254) 756-0954
CLIENT EDUCATION MATERIAL
I have received the Client Education printed material and a staff member of the EOAC
Compressive Energy Assistance Program (CEAP) and/or Community Services Block Grant
Program (CSBG) has explained to me the energy and money saving tips that this material
contains.
I understand that this form is for the Client Education items that I have received today. It does
not make EOAC liable for any other services for my home.
Yo Han recibido el material impreso y la educacion del cliente un miembro del personal de El
EOAC compression Programa de Asistencia para Energia (CEAP) y/o Servicios a la Comunidad
Block Grant Program (CSBG) me ha explicado la energia y consejos para ahorrar dinero que este
material contiene.
Yo entiendo que este formulario es para los elementos de clients de educacion que he recibido
hoy. No tiene EOAC responsible de los otros servicios para me casa.
O Energy Saver Booklet
De ahorro de Energia Folleto
O Calendar with energy saving tips
Calendario con consejos para ahorrar
energia
O Other: _______________________________
Otros:
Signed:
Client Signature
Firma de Cliente
Date
Fecha
Case Worker Signature
Firma de Trabajador de Casos
Date
Fecha
Signed:
9
Revised 1.5.15
EOAC
Texas Department of Housing and
Community Affairs requires that ALL 18
years and older household members that
do not have any income, complete the
attached Declaration of Income statement
and have the Statement of No Documented
Proof of Income form notarized before
eligibility can be determined on your case.
Please ensure that this form is complete
and notarized prior to your interview.
Thank You,
EOAC
10
Revised 1.5.15
DECLARATION OF INCOME STATEMENT
(DECLARACION DE INGRESOS)
I, ___________________________________________do hereby declare on ______________that:
(Yo) (Applicant’s Name/Nombre del Solicitante)
(declaro que en esta fecha) (date)
I have no documented proof of income due to the following:
(No tengo documentación que compruebe mis ingresos por la siguiente razón:)
EOAC
I am applying for assistance with the agency:
(Deseo aplicar para recibir asistencia de la agencia:)
My household consists of _______ persons and the following household members, 18 years and older that have earned the
following gross income during the 30 day period prior to the date of this application for assistance.
(En mi hogar viven ________personas. Los siguientes miembros de mi hogar tienen 18 años de edad o más y, durante los
últimos 30 días antes de llenar esta aplicación, han recibido ingresos. (Indique el nombre y los ingresos de cada miembro)
Name/
Nombre
Name
Nombre
Name/
Nombre
Name/
Nombre
Name/
Nombre
Gross Amount
Ingresos
Gross Amount
Ingresos
Gross Amount
Ingresos
Gross Amount
Ingresos
Gross Amount
Ingresos
My household’s gross income, for all household members 18 years and older, for the 30 day period prior to the
date of the application for assistance is $________________________;
(El total de los ingresos de mi hogar durante los últimos 30 días antes de la fecha de esta aplicación es de
$_____________________, y representa los ingresos para todos los miembros de mi hogar que tienen 18 años de edad
o más.);
and my household’s gross annualized income based on the 30 day period prior to the date of this application is
$______________
(El ingreso anual de mi hogar basado en los últimos 30 días antes de la fecha de mi aplicación es de $_________)
I certify that the above information for the income of all household members 18 years and older is true and correct to the
best of my knowledge and belief.
(Certifico que la información de ingresos proveída de los miembros de mi hogar que tienen 18 años o más es verdadera y
correcta según mi saber y entendimiento.)
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 proveída en esta aplicación será verificada hasta donde sea posible y que puedo ser
enjuiciado por haber proveído información falsa o fraudulenta.)
Applicant Signature/Firma
Street Address/Dirección
Date/Fecha
City/Ciudad
County/Condado
Subrecipient Representative
Reviewed by
Zip/Código Postal
Date
Signature and File
Date
11
STATEMENT OF NO DOCUMENTED
PROOF OF INCOME
I, ______________________________________, do hereby declare on ____________________
(Print name here)
(Date)
That I have no documented proof of income due to the following situation:
I certify that the above information is true and correct.
___________________________________
Client Signature
________________________
Date
This instrument was acknowledged before me this ______ day of __________________, 20____
__________________________________________
Notary Public, State of Texas
12
ECONOMIC OPPORTUNITIES ADVANCE CORPORATION OF PLANNING REGION XI
Client's Statement of Self-Employment Income
Declaracion de ingresos del negacio propio del cliente
1.
Name of Person Having Self-Employment Income:
Nombre de la persona que tiene ingresos de negocio propio:
2.
Describe what you did to earn this money:
Describa lo que hizo para ganarse este dinero:
3.
List your business income, include any and all tips, for the last 30 day including today.
Lista de ingresos de su negocio, incluyen consejos de todos y, para los últimos 30 días incluyendo hoy.
DATE
FECHA
INCOME
INGRESOS
AMOUNT
CANTIDAD
$
TOTAL SELF-EMPLOYMENT INCOME
TOTAL DE INGRESOS DEL NEGOCIO PROPIO
The above information is true, correct, and complete to the best of my knowledge. I understand that giving false
information could result in my being disqualified for fraud.
Segun mi leal saber y entender, toda esta informacion es cierta, correcta y completa. Comprendo que se doy informacion falsa
puedo ser discalificado por fraude.
Signature/Firma
Date/Fecha
01.05.15
13
EOAC
APPLY FOR CHILD SUPPORT
The Attorney General of Texas
Apply Online: http://childsupport.oag.state.tx.us/index.html
Once online you may apply for
- Establishment of paternity
- Establishment of child support, including if you already have an order
OR
Request an application
- Online
- By Phone, call 1-800-252-8014
REGISTER WITH WORK IN TEXAS
(TEXAS WORKFORCE)
Apply Online: www.workintexas.com
OR
By Phone: Monday - Friday from 8:00 a.m. to 5:00 p.m. CST
Falls County
230 Coleman
Marlin, TX 76661
254-803-3751
Bosque/Hill County
233 E. Elm Street
Hillsboro, TX 76645
254-582-8588
Freestone/Limestone County
517 Main
Teague, TX 75860
254-739-2887
McLennan County
1416 South New Road
Waco, TX 76711
254-754-5421
1.5.15
Assistance OTHER than EOAC you may
qualify for:
Assistance Paying Your Bill
LITE-UP Texas Program
The LITE-UP TEXAS program is designed to help qualified low-income individuals living in an area where
they can choose their service provider, reduce the monthly cost of electric service. The program will
provide discounts to eligible customers in the following months:

May, June, July, and August 2015 bills

An electric customer is qualified if the customer is currently receiving: Medicaid and SNAP. If you are not
in one of the qualified programs listed above, you can still qualify in the program if your household
income is at or below 125 percent of the federal poverty guidelines.
If you are not a participant in the above qualified programs but think you qualify based on household
income (see chart below) you can self-enroll by calling toll-free 1-866-454-8387 and request an
application or by printing an application from this website.
Number in Household Annual Income (125%)
1
$14,713
2
$19,913
3
$25,113
4
$30,313
5
$35,513
6
$40,713
7
$45,913
8
$51,113
Each additional add
$5,200
IMPORTANT: The information on the electric bill (Name, Address, etc..) must match the information
of the participant in the qualified program or the self-enrolled application.
You can fax or email your completed and signed scanned copy of your application, with all the backup
information, to the administrator at:
1-877-215-8018 (toll free fax)