1 KATHLEEN ROBISON HUNTSMAN HOUSING APPLICATION INSTRUCTIONS ***Please Detach before returning application*** 1. Please complete the attached application in its entirety. Incomplete applications will not be processed. The attached KRH and Housing Authority Release of Information forms must be signed before your application will be processed. 2. Applicants must have their referral source fill out and return the Agency Referral Form. The referral form may be returned with the entire completed application or faxed directly by the person filling out the form. 3. Return applications to the YWCA Receptionist. You can also mail your application to 322 East 300 South Salt Lake City, UT or fax it to KRH (801) Please Write Attention Lam 4. Before an interview can be scheduled: a. Submit Income verification- 1) Letter from employer including the start date, hours worked per week, rate of pay and supervisors name and phone number or two copies of most current check stubs OR 2) Printout of other income (i.e. TANF, Disability, Unemployment, Child Support, etc). b. Immigration and Naturalization Services must do a residency check on all people who have not been born in the United States for eligibility and rent status. Please fax or send INS cards, green cards, photo IDs and Social Security cards for all of you and your children if you have not been born in the United States. 5. An interview will be scheduled with applicants who meet the basic eligibility requirements to assess if they meet the criteria for acceptance and participation. Applicants will be contacted through their home (shelter) number, work number and/or emergency contact. It will be the applicant s responsibility to return messages. Please make arrangements for child care for this interview. The person who referred you to the KRH Housing Program should have filled out the Agency Referral form. You must bring the following documentation with you: Letter verifying domestic violence involvement from referring agency (If you are self referred, you must provide a copy of a police report or protective order) Custody agreement (if applicable) Protective order (if applicable) Picture ID of everyone in the household over 18 Social Security cards for everyone in the household Divorce Decree (if applicable) Bank Statements Income Tax Returns
2 6. In order to prepare for transition into the KRH program, applicants will be given a small task to complete after the interview. It is the applicant s responsibility to contact the interviewer upon completion of the task. The interviewer will meet with the applicant for a brief review of the task and to gather any other needed documentation or information. Failure to complete the assigned task is grounds for denial into the KRH program. Tasks may include but are not limited to: scheduling an intake for domestic violence counseling, applying for financial assistance, or resolving unpaid balances with utility companies. IMPORTANT: Applicants who do not contact their interviewer regarding their task within 2 weeks after the interview date will be removed from the waiting list. 7. All applicants will be screened through a criminal history background check. 8. Eligible applicants will be placed on a waiting list. It is important that we have permanent phone numbers, or you will need to contact us to determine the status of your application. Please note that the KRH program gives priority to applicants who are currently residing at the YWCA crisis shelter and residential programs. Cancellation Policy If you cancel your interview appointment more than two times, another interview will not be scheduled. You will need to wait 30 days and submit a new application. No Show Policy If you do not show-up for your scheduled interview (or intake), your interview (or intake) will not be rescheduled. You will need to submit a new application after 30 days. YWCA East 300 South - SLC, UT Phone: Fax: KRH Apartments E 300 S - SLC, UT Phone: (housing manager) Fax: (Lam, Program Director, can answer program questions; phone: ). Rev.8/06 KRH Vision Statement We lend our collective efforts to making the YWCA s Kathleen Robison Hunstman program a safe, comfortable, dignified place where women and children can receive support and access to resources in order to enhance the quality of their lives. *Retain This for your records*
3 KATHLEEN ROBISON HUNTSMAN HOUSING PROGRAM APPLICATION at the YWCA of Salt Lake City 322 East 300 South Salt Lake City, UT Phone (801) Apt address: 338 East 300 South The YWCA Kathleen Robison Huntsman (KRH) Housing Program is a transitional housing program designed to help battered women with children improve their quality of life and end the cycle of domestic violence. Families can live at the KRH Apartments for up to two years. Rent is collected each month to provide women with a two or three bedroom apartment, laundry facilities, case management services and group meetings. Residents set self-sufficiency goals with a case manager and work toward the achievement of those goals by participating in the program. Criteria for Acceptance and Participation: 1. Applicant must be a victim of domestic violence. Applicants may be referred from other community agencies or service providers. Applicants who are self-referred must provide documentation of domestic violence. 2. Applicant must be a female who is 18 years or older. 3. Applicant must be either pregnant, the head of household and/or the primary caretaker of dependent children. 4. Applicant must be homeless due to domestic violence. 5. Applicant must have the ability and desire to become self-sufficient and end the cycle of domestic violence. 6. Applicant must be wiling to take the necessary steps to provide for the safety of herself, her children and the KRH Housing community. Those steps may include the acquisition and enforcement of a protective order. 7. Applicant must be currently involved or demonstrate capability of involvement in employment, employment training, school, or volunteer work. Funding by general assistance, emergency work program or disability is acceptable as long as the resident is actively involved in a training program, school and/or seeking employment. 8. Applicant must be willing and capable of actively participating in the KRH Housing services. Specifically, applicant must work on an individualized self-sufficiency plan with a case manager, attend 13 credits of groups, and work or go to school 20 hours per week. Residents may be required to participate in treatment or therapy outside of the KRH Housing Program as a part of their individualized self-sufficiency goals. Residents and/or their children will be referred to treatment or therapy by their case manager and will be responsible for the cost of services. 9. Applicant must be able to function within a community setting, caring for herself and her children without requiring assistance with activities of daily living or mental health services other than those provided through referral by
4 the KRH Housing Program case manager. Applicant must also be able to responsibly monitor her own and/or her children's medication(s). 10. Applicant must be free from drug or alcohol dependence. Those with a history of substance abuse must provide documentation regarding their participation in a substance abuse treatment program. If applicant has a history of alcohol and/or drug dependence or there is suspicion of current use, a drug test may be requested. If analysis comes back positive, applicant may be asked to leave. 11. Applicant must agree to comply with KRH Housing Program rules and regulations and the YWCA mission and vision. YWCA Mission: The empowerment of women and the elimination of racism. YWCA Vision: Peace, justice, freedom and dignity for all people. 12. Applicant must demonstrate the ability to live with a diverse population of women and children and to respect different lifestyles and choices. 13. Applicant must complete a program application, supplying all information requested and complete an interview with KRH Housing Program staff. The first 60 days of program participation is a probationary period. Appropriateness for the program will be evaluated during that period. If it is determined that a woman is not appropriate for the program, or that the YWCA cannot meet her needs, staff will assist her in locating other housing. Agreement to Participate in Services I, (please print) have applied for the KRH Housing Program, and have read and understand the above criteria for acceptance. If accepted into the program, I agree to abide by the conditions listed above and understand that the purpose of the program is to help me achieve greater independence. Applicant s Signature Date: If applicant will need the interview conducted in a language other than English, please note the language here:. AGENCY REFERRAL FORM
5 This form must be completed by the applicant=s referral agency. Acceptable referral sources include: shelter workers, licensed therapists, substance abuse counselors, DCFS workers, or school counselors. Applicant name: (please print) Referral source: (Name)(Agency)(Phone) I hereby request and authorize the above named referral source to release information to the KRH Program pertinent to mine or my children=s current social, drug, medical, and psychological situation for purposes of eligibility determination. Signature of ApplicantDate Please answer the following questions in complete, descriptive sentences. 1. What services has your agency provided this family? 2. Please describe the family=s strengths: 3. Please describe what you believe to be the family=s weaknesses: 4. Please describe any history of drug or alcohol abuse in this family: 5. What needs has the family expressed to you or others in your agency? 6. Why and how do you think this family would benefit from the KRH program? REFFERAL SOURCE: When you have completed this form, fax to (801) (ATTN: Housing Assistant) or submit in person along with the entire application packet to the YWCA receptionist. If you have any questions, please call YWCA of Salt Lake City 322 E 300 S Salt Lake City, UT 84111
6 General Information 1. Today=s Date Name Social Security # Date of Birth Age Address (Street) (City, State) (Zip) Phone # Work Phone # 2. Name of person we can contact if you cannot be reached at the above address: (Name/Relationship) (Address) (Phone) 3. Marital Status: Single [ ] Married & living with spouse [ ] Married and not living with spouse [ ] Divorced [ ] Widowed [ ] Common Law [ ] Living together [ ] Civil Union [ ] Other [ ] 4.Ethnic background: Were you born in the United States of America? Yes No If no: How long have you lived in the United States? Have you applied for residency? What is your residency status as of today? Do you have a work permit? Are any of your children citizens of the United States? If so, which one(s)? What is your INS number? What is your first language? Do you need an interpreter? 5. I was referred to the Kathleen Robison Huntsman Housing by (This person must complete the attached agency referral form.) 6. List your last two Landlords/Address/Phone #: 7. Have you ever had housing assistance before? ( ) yes ( ) no If so, When? Where? 8. Please list any arrests/convictions that would appear on your criminal history/background report. (You may be required to submit court papers or police reports.) 9. Please list the names of those who would be living at the KRH Apartments.
7 Current Situation 1. What is your current living situation? [ ] YWCA Battered Women's Shelter [ ] Other Shelter: (name of shelter) [ ] Living on the street (i.e. in a car, park, sidewalk, abandoned building) [ ] Transitional Housing Program (name of program) [ ] Rental housing. If so, are you currently being evicted? [ ] yes [ ] no [ ] Mental Health or Substance abuse treatment facility: [ ] Living with an abusive partner [ ] Other. Please explain: 2. Please explain the most recent incidence of Domestic Violence (attach pages as needed): 3. Name of abuser DOB Last known/current address: SS# Employment/Education History 1. Are you currently employed? [ ] yes [ ] no 2. Please list last three employment situations listing most recent employment first. *Employer: Address: Supervisor: Length of Employment: From *Employer: Address: Supervisor: Length of Employment: From *Employer: Address: Supervisor: Length of Employment: From Position Held: Phone: To Position Held: Phone: To Position Held: Phone: To 3. Did you graduate from high school? [ ] yes [ ] no Or obtain your GED? [ ] yes [ ] no 4. Please list any special training (including college experience) you have received.
8 8 5. Please list any reason why you feel you cannot work or go to school: Source of Income 1. What is your current source(s) of income? [ ] wages/salaries [ ] welfare assistance [ ] unemployment [ ] social security (disability insurance) [ ] child support 2. What is your total monthly income? 3. What Social Services have you received in the past two years(including any benefits - i.e. disability, AFDC, general assistance, food stamps, etc.)? Physical/Mental Health History 1. Do you or your children have any physical/mental conditions which may limit you or your children's activity? [ ] yes [ ] no Please explain: 2. Current Medication(s) (include name of medication, what it is prescribed for and how often it is taken): MEDICATION PRESCRIBED FOR FREQUENCY USED 3. Physician (Name) Phone 4. Are you currently seeing a counselor/therapist? [ ] yes [ ] no Therapist/Agency Name Address Phone 5. Have you had any history of hospitalizations for physical/mental illness (other than
9 9 childbirth)? [ ] yes [ ] no If yes, please list: *Hospital From To Diagnosis *Hospital From To Diagnosis *Hospital From To Diagnosis Children 1. Please complete the following for each of your children under age 18, even if they do not live with you. *Name Social Security # Date of Birth Age Grade Ethnicity School Who has custody of this child? *Name Social Security # Date of Birth Age Grade Ethnicity School Who has custody of this child? *Name Social Security # Date of Birth Age Grade Ethnicity School Who has custody of this child? *Name Social Security # Date of Birth Age Grade Ethnicity School Who has custody of this child? 2. Who cares for your children when you are at work, school or are unable to care for them? 3. Have any of your children been involved with juvenile court? [ ] Yes [ ] No Please explain: 4. Do any of your children have any physical, mental or emotional issues that they are receiving treatment for? [ ] yes [ ] no If yes, please identify the child, the issue, and the treatment being received: 5. For future contacting purposes, Is there someone who always knows how to get in touch with you? Name Phone Address Relation KATHLEEN ROBISON HUNTSMAN APPLICATION SOLICITUD PARA KATHLEEN ROBINSON HUNTSMAN
10 10 This application is not a rental agreement, contract or lease. All applications are subject to the approval of the owner or managing agent. Esta solicitud no es un acuerdo de alquiler, contrato o lease. Todas las solicitudes estarán sujetas a la aprobación por el dueño o el agente encargado. DRUG FREE ZONE: It is our aim to ensure that this apartment community is a drug-free zone. The use and sale of controlled substances will not be tolerated. By signing this application from, I verify my support for this policy. ZONA SIN DROGAS Es nuestro objetivo asegurar que esta comunidad de appartamentos sea una zona sin drogas. El uso y la venta de substancias controladas no será tolerada. Al firmar esta hoja de solicitud, yo verifico y apoyo esta regla. CONSENT: I/we have authorized and direct any Federal, State, or local agency, organization, business or individual to release to the Kathleen Robison Huntsman Apartments any information or materials needed to complete and verify my application for residency with the Kathleen Robison Huntsman Apartments. CONSENTIMIENTO Yo (o nosotros) autorizo y permito que cualquier agencia, organización, negocio o individuo de carácter federal, estatal o local ceda cualquier información o materiales necesitados para completar y verificar la solicitud para residir en los Apartamentos Kathleen Robinson Huntsman. INFORMATION COVERED I understand that depending on adopted policies and requirements, previous or current information regarding my household may be hended. Verifications and inquiries that may be requested, include but are not limited to: INFORMACIÓN INCLUIDA Entiendo que dependiendo de los reglamentos y requisitos adoptados, puede ser necesitada información actual o previa referente a los miembros de la familia. Verificaciones y solicitud de informacion que puede ser requerida incluye pero no se limita a: Identity and Marital Status/ Identidad y Estado Civil Credit History/ Historial De Crédito Employment, Income, and Assets/ Empleo, Ingresos y Activos Criminal Activity/ Actividad Criminal Residences and Rental Activity/ Residencias y Alquileres GROUPS OR INDIVIDUALS THAT MAY BE ASKED: The groups or individuals that may be asked to release the above information (depending on location requirements include but are not limited to) GRUPOS E INDIVIDUOS QUE PUEDEN SER INQUIRIDOS: Los grupos o los individuos a los que se les puede pedir ceder la información señalada arriba (dependiendo de los requisitos de la localización), incluye pero no se limita a:
11 Previous Landlords/ Caseros anteriores Law Enforcement Agencies/ Agencias de policia Schools and Colleges/ Escuelas e instituciones educativas Courts and Post offices/ Sistema judicial y Oficinas postales Veterans Administration/ Oficina de Veteranos de guerra Past and Present Employers/ Empleadores pasados y presentes State Unemployment Agencies/ Agencias estatales de desempleo Retirement Systems/ Sistemas de Jubilación Social Security Administration/ Administración de la Seguridad Social Welfare Agencies/ Agencias de ayuda social 11 Banks and Financial Institutions/ Bancos e instituciones financieras Credit Bureaus and Providers/ Oficinas de crédito y proveedores Utility Companies/ Companias de Utilidades Aging Services/ Servicios de la Tercera Edad Support or Alimony Providers/ Proveedores de manutención y de pensión alimenticia General/ DATOS GENERALES Name/Nombre: Address/ Dirección: Zip Code/Código postal Home phone/teléfono de casa Work Phone/Teléfono del trabajo List all persons who live with you/ Pon en la lista a todas las personas que viven contigo: Full Name/ Nombre completo Relationship to Head/ Tipo de relación con el/la cabeza de familia Cabeza de familia Segundo cabeza Social Security# Seguridad Social D.O.B Fecha Nacimiento Place of Birth/ Lugar de Nacimiento (ciudad, Estado) Sex/ Sexo Are you participating in a government funded training program such as JTPA or PASS? _No/Yes If yes, which program:
12 Está participando actualmente en un programa de entrenamiento patrocinado por el gobierno como ASUTPA o PASS? No/_Si Si contestó sí, nombre el programa: TOTAL HOUSEHOLD INCOME/INGRESOS TOTALES DE LA FAMILIA List all money earned or recieved by everyone in your household. This includes money from wages, self-employment, child support, contributions, Social Security, disability payments (SSI), Workers Compensation, retirement benefits, AFDC, Veterans Benefits, rental property income, stock dividends, income from bank accounts, alimony, student income, and any other source. If you receive any of the incomes listed above, please list amount received below. Añada a la lista las ganancias de dinero recibidas por cualquier miembro de la familia. Esto incluye ingresos de empleo, de auto-empleo, manutención de menores, contribuciones, Seguridad Social, pagos por incapacidad (SSI), indemnizaciones, beneficios de jubilación, AFDC, Beneficios de veteranos de guerra, ingresos de alquiler de propiedades, dividendos de mercado de valores, ganancias de intereses en cuentas de bancos, pensiones alimenticias, ingresos de estudiantes, y cualquier otro ingreso. Si Usted recibe cualquiera de estos ingresos nombrados, por favor, liste la cantidad recibida abajo: 12 Household member/ Source of income/ Amount received per month/ Employment income per hour/ Employment hours per week/ Miembro de la Familia Fuente de Ingreso Cantidad recibida por mes Ingresos de empleo por hora # Horas de empleo por semana Is your family currently receiving food stamps? No Yes Está su familia actualmente recibiendo estampillas de comida? NO SI Is your family currently receiving Medicaid/ Children s Health Insurance Program(CHIP):No/Yes Está su familia actualmente recibiendo Medicaid/ (CHIP) Programa de Seguro Médico para Niños? No SI ASSETS: Do you have any of the following: No Yes If yes, please fill out and provide verification. VALORES: Tiene alguno de los siguientes No SI verificación En caso de que sí, por favor provea Checking Acct#/Num. cuenta corriente Balance $ Name of Bank/Nombre del Banco Savings acct#/num cuenta ahorros Balance $ Name of Bank/Nombre del Banco Money Market Account/Cuenta de dinero de mercado Name of Bank/Nombre del Banco
13 Do you own any bonds?/tienes algún tipo de bonos? Aproxímate Value/Valor aproximado Do you own any real estate?/es Usted dueño de alguna propiedad? Aproxímate Value/Valor aproximado CHILD CARE EXPENSES/ CUIDADO DE SUS HIJOS Provide Verification of your Childcare Costs/ Provea verificación del coste del cuidado de sus hijos. Do you pay for babysitting? No Yes If yes please fill out. Paga usted por una niñera? NO SI, Si contestó si, por favor rellene: Provider s Name/Nombre de la proveedora Provider s address/dirección de la proveedora Zip Code/Código Postal Telephone number/numero de teléfono Number of children receiving child care services/número de hijos que recibió servicios de cuidado de niños EDUCATION/ TRAINING/ EDUCACIÓN / ENTRENAMIENTO: Please check level of education for Head of Household/ Por favor, señale el nivel de educación del cabeza de familia: GED High School/Preparatoria College/Universidad Vocational Job/Trabajo vocacional Number of years of school completed by head of household/ Número de años de escuela terminados por el cabeza de familia CHILD SUPPORT/MANUTENCIÓN DE MENORES: Do you receive child support from the Office of Recovery Services (ORS)/ Recibes manutención de menores del Office of Recovery Services (ORS) NO SI/YES If you answered yes, plese provide verification/si contestó si, por favor provea verificación. Is child support received from an Absent Parent/ Es la manutención de menores recibida de uno de los padres que están ausentes? NO _SI/YES. If you answered yes, please fill out and provide a statement from the absent parent/ Si contestó sí, por favor rellene y provea una declaración del padre ausente. 13 We need to have the absent parent s name and current address/ Necesitamos tener el nombre y dirección actual del padre ausente Child s Name/ Absent Parent s Full Name/ Absent Parents address/
14 14 Nombre del Niño Nombre completo del padre ausente Dirección completa del padre ausente. Please answer each question completely. If you have answered yes, complete the additional information/ Por favor responda a cada pregunta completamente y si contesta Si, complete la información adicional. Question/Pregunta Are any household members full time students? Yes/ Si No Additional Information/ Información Adicional Who/Quién? Es algún miembro de la familia estudiante a tiempo completo? Are any household members temporarily absent? Está algún miembro de la familia temporalmente ausente? Are any household members permanently absent? Who/Quién? Who/Quién? Está algún miembro de la familia permanentemente ausente? Are you separated, but not divorced from your spouse? Está usted separada pero no divorciada de su esposo? Will you be receiving housing asístanse from a local agency? Agency/Qué agencia? Recibirá asistencia para pagar su hogar de alguna agencia local? VEHICLE INFORMATION/INFORMACIÓN DEL VEHÍCULO Make: Model: Color: Year: Lic # State: Marca: Modelo: Color: Año #Placa Estado EMERGENCY REFERENCES/REFERENCIAS PARA CASOS DE EMERGENCIA Please provide the names of two people who can be contacted in case of emergency/ Por favor provea los nombres de dos personas que puedan ser contactadas en caso de
15 15 emergencia: Name/Nombre Phone/Teléfono Address/Dirección Relationship/Relación Name/Nombre Phone/Teléfono Address/Dirección Relationship/Relación COMPUTER MATCHING NOTICE AND CONSENT/ NOTICIA Y CONSENTIMIENTO DE EQUIPARACIÓN DE LOS DATOS DADOS A LOS DE LA COMPUTADORA. I understand and agree that the Kathleen Robison Huntsman Apartments may conduct computer matching programs to verify the information supplied on my application. If a computer match is done, I understand that I have a right to notification of any adverse information found and a chance to disprove that information. Entiendo y consiento que los Apartamentos Kathleen Robinson Huntsman conduzca un programa de equiparación para verificar la información proporcionada en mi solicitud. Si la equiparación por computadora se hace, entiendo que tengo el derecho a ser notificada de cualquier información adversa encontrada y que tengo la oportunidad de dar prueba contraria a esa información. SIGNATURE CLAUSE / CLÁUSULA FIRMADA I/We certify that answers given herin are trae and complete to the best of my knowledge.i authorize investigation of all statements container in this applicatio for continued residency as may be necessary. I understand that any misrepresentation may result in the denial of my application. I authorize the Kathleen Robison Huntsman Apartments, its subsidiaries, and its agents to investigate my credit worthiness through any credit bureau or other reasonable means. I have read this application and understand it. Yo/Nosotros verifico/amos que las respuestas contenidas aquí son tan verdaderas y completas como mi/ nuestro conocimiento alcanza. Yo autorizo la investigación de todas las declaraciones contenidas en esta aplicación para continuar mi residencia cuando sea necesario. Entiendo que cualquier falsa representación puede resultar en el rechazo de mi aplicación. Autorizo a los apartamentos Kathleen Robinson Huntsman, sus subsidiarios y a sus agentes, a investigar mi capacidad de crédito a través de cualquier oficina de crédito o por otros medios adecuados. Yo he leído esta solicitud y la entiendo. ALL ADULT FAMILY MEMBERS OF THIS HOUSEHOLD MUST SIGN BELOW TODOS LOS MIEMBROS ADULTOS DE ESTA FAMILIA DEBEN FIRMAR ABAJO: PRINTED NAME/ NOMBREI MPRESO SOC-SEC# # SEG SOCIAL Signatura/FIRMA DATE OF BIRTH/ FECHA DE NACIMIENTO Date/ FECHA DE HOY