Sweetwater Family Resource Center Application

Physical Address
Mailing Address

(If different from physical address)

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For what type of assistance are you applying?
Do you have an Eviction Notice or Past Due Notice?
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Have you applied for SNAP benefits?
Issues Involved in Need for Assistance (check all that apply)
Have you been affected by COVID-19?
COVID-19 Information
Are you seeking services because you have been impacted by the COVID-19 health crisis?
At any point, have you or a member of your immediate household been diagnosed with COVID-19?
Are you financially struggling due to COVID-19 related healthcare costs (even if you were tested and received a negative test result)?
Have you experienced a loss of income due to the COVID-19 public health crisis?
Have you experienced a loss of employment as the result of the COVID-19 public health crisis?
Have you experienced a housing crisis as the result of the COVID-19 public health crisis?
Only upload if you tested positive
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Upload a letter from your employer or recent pay stubs showing decreased hours.
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Household Members

Household Type

Please complete the information for ALL household members (including yourself)

Household Member #1 (self)
General Information
Disability
Health Insurance Type(s)
Employment Information
Most Recent Pay Stub or W-2
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Other Income Sources

Zero Income Statement

I certify that at the present time have not received any income within the past 30 day from any source(s). I also certify that I have applied for assistance with the Sweetwater Family Resource Center and the above information is true and correct and that I am aware that I may be penalized or denied benefits if I knowingly provide false information.

Domestic Violence History
When did the experience occur?
Are you currently fleeing?
Household Member #2
General Information
Disability
Health Insurance Type(s)
Employment Information
Most Recent Pay Stub or W-2
Upload requirements
Other Income Sources

Zero Income Statement

I certify that at the present time have not received any income within the past 30 day from any source(s). I also certify that I have applied for assistance with the Sweetwater Family Resource Center and the above information is true and correct and that I am aware that I may be penalized or denied benefits if I knowingly provide false information.

Domestic Violence History
When did the experience occur?
Are you currently fleeing?
Household Member #3
General Information
Disability
Health Insurance Type(s)
Employment Information
Most Recent Pay Stub or W-2
Upload requirements
Other Income Sources

Zero Income Statement

I certify that at the present time have not received any income within the past 30 day from any source(s). I also certify that I have applied for assistance with the Sweetwater Family Resource Center and the above information is true and correct and that I am aware that I may be penalized or denied benefits if I knowingly provide false information.

Domestic Violence History
When did the experience occur?
Are you currently fleeing?
Household Member #4
General Information
Disability
Health Insurance Type(s)
Employment Information
Most Recent Pay Stub or W-2
Upload requirements
Other Income Sources

Zero Income Statement

I certify that at the present time have not received any income within the past 30 day from any source(s). I also certify that I have applied for assistance with the Sweetwater Family Resource Center and the above information is true and correct and that I am aware that I may be penalized or denied benefits if I knowingly provide false information.

Domestic Violence History
When did the experience occur?
Are you currently fleeing?
Household Member #5
General Information
Disability
Health Insurance Type(s)
Employment Information
Most Recent Pay Stub or W-2
Upload requirements
Other Income Sources

Zero Income Statement

I certify that at the present time have not received any income within the past 30 day from any source(s). I also certify that I have applied for assistance with the Sweetwater Family Resource Center and the above information is true and correct and that I am aware that I may be penalized or denied benefits if I knowingly provide false information.

Domestic Violence History
When did the experience occur?
Are you currently fleeing?
Household Member #6
General Information
Disability
Health Insurance Type(s)
Employment Information
Most Recent Pay Stub or W-2
Upload requirements
Other Income Sources

Zero Income Statement

I certify that at the present time have not received any income within the past 30 day from any source(s). I also certify that I have applied for assistance with the Sweetwater Family Resource Center and the above information is true and correct and that I am aware that I may be penalized or denied benefits if I knowingly provide false information.

Domestic Violence History
When did the experience occur?
Are you currently fleeing?
Household Member #7
General Information
Disability
Health Insurance Type(s)
Employment Information
Most Recent Pay Stub or W-2
Upload requirements
Other Income Sources

Zero Income Statement

I certify that at the present time have not received any income within the past 30 day from any source(s). I also certify that I have applied for assistance with the Sweetwater Family Resource Center and the above information is true and correct and that I am aware that I may be penalized or denied benefits if I knowingly provide false information.

Domestic Violence History
When did the experience occur?
Are you currently fleeing?
OneStep Forward*

Note: Participation in OneStep Forward is required and you must prove such participation by uploading a PDF file showing enrollment, completion, or participation in one or more of the programs listed below. *Proof Required

Are you currently attending or have you completed any of the following in the past 6 (six) months?
Verification

I hereby verify that my answers on this application are truthful. I understand that funds are limited, an eligibility is not a guarantee of assistance. I understand that eligibility includes income, need, provision of required documents, and the requirement to take "One Step Forward". I understand that any expectations or extensions will be at the sole discretion of the Sweetwater Family Resources Center (SFRC), and that I may be required to update information following assistance.

I understand that I may be contacted in the months following assistance. I agree to respond to calls and requests for information from the Sweetwater Family Resources Center about my experience and my situation following assistance.

I authorize SFRC to verify the information contained in this application, and I authorize those contacted by SFRC to provide the information requested. I have had an opportunity to the HMIS Privacy Notice. I agree to hold harmless those persons and agencies providing information, as well as the Sweetwater Family Resources Center and its staff members.

Self-Declaration of Income

Please initial next to the choice that best describes you. (adults only)

I certify, under penalty of perjury, that I currently receive the income indicated above.

I certify, under penalty of perjury, that I do not have any income from any source at this time.

Wyoming Homeless Collaborative

What is WHC Coordinated Entry? How will my information be used?

WHC Coordinated Entry is a collaboration through which participating agencies collectively measure and plan for the needs of individuals and families experiencing homelessness in Wyoming.

With your permission, you will be assessed by a staff person or volunteer for an agency that participates in WHC Coordinated Entry. The results of your assessment will be entered into a database called the Homeless Management Information System (HMIS).

You have the right to decline to participate. If you opt to participate, your assessment results will be provided to the Coordinated Entry Team -- a multidisciplinary team that facilitates referrals to several housing projects. If a project opening is identified for which you are potentially eligible to be prioritized, attempts will be made to reach you at the contact information you provide so that you can undergo project-level assessment.

Homeless Prevention Services: Assessment for homeless prevention services may or may not be assessed through the coordinated entry process.

What agencies currently participate in some aspect of WHC Coordinated Entry?

  • Campbell County YES Transition in Place (TLP)
  • COMEA Shelter
  • Community Action of Laramie County
  • Community Action Partnership of Natrona County
  • Community Connections
  • Council of Community Services
  • Fremont Good Samaritan Rescue Mission
  • Recover Wyoming
  • Seton House
  • Sweetwater Family Resource Center
  • Teton County Good Samaritan Rescue Mission
  • United Way 211
  • Volunteers of America - Northern Rockies
  • Veterans Administration - Cheyenne
  • Wyoming Rescue Mission
How do I opt to release (or not release) my information for purposes of WHC Coordinated Entry? (Check the box that applies)

Wyoming Homeless Collaborative

Consumers Informed Consent & Sharing of Information Authorization

I/We

and

understand information about me and/or my dependents listed below is entered into a database system called ServicePoint. This system helps to better understand homelessness, to improve service delivery and to evaluate effectiveness of services provided. Participation in data collection is a critical component of our community's ability to provide the most effective services an housing possible.

The information that is collected is protected by limiting access to the database and limiting what information may be shared. Access to the data and sharing of the data is in compliance with the standards set by the federal, state and local regulations governing confidentiality of client records. Every person and agency that is authorized to read or enter information into the system has signed an agreement to maintain the security and confidentiality of the information.

List all Dependent Children, under 18, in the household, if any:

By signing this form, I authorize the following:

The information collected by this agency will be included in ServicePoint and only partner agencies, which have entered info an HMIS Agency Participant Agreement at which I have obtained or sought out services, may use my information to...

  • Produce a client profile at intake that will be shared with collaborating agencies
  • Produce aggregate level reports regarding use of services
  • Track individual program-level outcomes
  • Identify unfilled service needs and plan for enhancements
  • Allocate resources among agencies engaged in services

By signing this form, I authorize the following:

I authorize the partner agencies and their representatives to share basic information regarding my family members listed below and/or me. I understand this information is for assessing my/our needs for housing and other services.

Agency Info Authorization
  • Name
  • Date of Birth
  • Social Security Number
  • Gender
  • Ethnicity and Race
  • Client Location
  • Veteran Status
  • Photo (if applicable)
Agency Info Authorization
  • Homeless History
  • Family Composition
  • Income/Non-cash
  • Domestic Violence
  • Entry/Exit Information
  • Disabling Condition
  • Housing Information
  • Health Insurance Status
  • Measurement Score (VI-SPDAT)

I Understand That:

The partner agencies have signed agreements to treat my information in a professional and confidential manner. I have the right to view the client confidentiality policies used by the HMIS partner agencies.

Staff members of the partner agencies who will see my information have signed agreements to maintain confidentiality regarding my information.

The release of my information does not guarantee that I will receive assistance; my refusal to authorize the use of my information does not disqualify me from receiving assistance.

My records are protected by federal, state, and local regulations governing confidentiality of client records and cannot be disclosed without my written consent unless otherwise provided for in the regulations.

This authorization will remain in effect until I revoke it in writing; I my revoke authorization at any time. If I revoke my authorization, all information about me already in the database will remain.

This release will remain in effect for 1 year from the date this ROI is signed.

Auditors or funders who have legal rights to review the work of this agency may see my information in HMIS related to the services I received and funded by their Department(s).

ESG House Options and Resources Eligibility

"But For" Certification

This document is to certify that the above-named applicant or household has explored all re-housing options and all available resources. The case manager also certifies that a comprehensive assessment was completed and that the findings are such that the above-named applicant or household would become or remain homeless but for ESG Homelessness Prevention or RRH assistance.


Client Certification

Under penalty of perjury I,

affirm the following statements to be true.

  1. I affirm that I have explored all housing options (family, friends, public housing, private housing) and that I have not been able to secure housing.
  2. I affirm that I have accurately reported my family composition and total family income.
  3. I affirm that my household lacks the financial resources and support networks needed to obtain immediate housing (i.e. start-up costs, etc).
  4. I affirm that I am not receiving financial assistance for the same reason that I am applying for ESG funds.
  5. I affirm that I would become or remain homeless but for ESG assistance.