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The CARES Act and other available funding through (City of Arlington, Texas)

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ARLINGTON CARES ASSISTANCE APPLICATION
1 of 9 pages updated 01-27-2021
The CARES Act and other available funding through the City of Arlington and the Arlington Housing Authority
provide persons who are in imminent danger of eviction and at risk of becoming homeless with assistance
funded by the U.S. Department of Housing and Urban Development (HUD) and other sources to prevent
evictions, prevent homelessness, and in some cases with case management services. This application is a
universal application for a variety of programs, and staff will determine the appropriate form of assistance.
ELIGIBILITY FOR HOMELESS PREVENTION OR HOMELESS ASSISTANCE: Case management services and
financial assistance is provided to eligible applicants as funding resources are available. Completion of this
application in no way guarantees financial assistance or services. Programs have varying eligibility
requirements. The chart below is a guide to determine eligibility based on funding source.
HUD Income Guidelines
To determine eligibly, income of all adult household residents aged 18 or over, unless they are a full-time
student, will be included in the household income determination. This includes self-employment wages,
TANF, alimony, Social Security benefits, Veteran’s benefits, disability payments, child support, rental property,
stock dividends, income from bank accounts, unemployment, retirement accounts, regular gifts of money
from friends, family, church or other social agencies. Money earned from providing services and interests
from bank accounts or investments must be disclosed.
Applicants must authorize the City staff to verify any and all information provided by any means necessary to
determine program eligibility. Applicants will be required to certify that the information provided is true and
will be subject to federal prosecution for knowingly making false statements. THIS INFORMATION WILL
REMAIN CONFIDENTIAL AND WILL BE USED SOLEY FOR THE PURPOSE OF ESTABLISHING YOUR ELIGIBILITY FOR
THIS PROGRAM.
Household
Size
(<30% AMI)
(<50% AMI)
(<60% AMI)
(<80% AMI)
1
$17,150
$28,550
$34,260
$45,650
2
$19,600
$32,600
$39,120
$52,200
3
$22,050
$36,700
$44,040
$58,700
4
$26,200
$40,750
$48,900
$65,200
5
$30,680
$44,050
$52,860
$70,450
6
$35,160
$47,300
$56,760
$75,650
7
$39,640
$50,550
$60,660
$80,850
8
$44,120
$53,800
$64,560
$86,100
ARLINGTON CARES ASSISTANCE APPLICATION
2 of 9 pages updated 01-27-2021
APPLICATION PACKET INSTRUCTIONS AND CHECKLIST
The list below is a comprehensive list of information that needs to be submitted with your application.
Please include this list with your application and indicate if any items are not applicable to your
application. Please include documentation for any and all sources of income from all members in your
household. Applications that are incomplete will be denied.
If you need an application in another language, please email homelessassistance@arlingtonhousing.us
IDENTIFICATION – Current photo ID, and copy of social security card and birth certificate for ALL
household members
EMPLOYMENT VERIFICATION - Four current and consecutive paycheck stubs with year-to-date
earnings or a letter from employer on Company letterhead that includes Company fax number
UNEMPLOYMENT - Original award letter from Unemployment Compensation and current
payment history printout or exhaust letter, dated within the last 60 days
TANF/SNAP - Texas Department of Human Services computer printed statement of current
benefits or cancellation of benefits letter, dated within the last 60 days
CHILD SUPPORT/ALIMONY - For child support, income verification letter dated within the last 60
days. For alimony, notarized letter from the provider and/or payment history
SSI/SSDI/SOCIAL SECURITY BENEFITS - Texas Department of Human Services computer printed
statement of current benefits or cancellation of benefits letter, dated within the last 60 days
BANK ACCOUNTS/ASSETS – Last 2 consecutive checking and savings statements and a current
statement for mutual funds, annuities, trust, inheritances, and legal settlements
LEASE - Copy of your current lease agreement (include ALL pages of the lease) or hotel bill
EVICTION NOTICE - Copy of your Eviction Notice and / or Notice to Vacate letter, if applicable
UTILITY DISCONNECT/LATE NOTICE - Copy of your most current past due electric, water, and gas
bills
HOUSEHOLD EXPENSES – Copy of your last 2 electric and water bills.
LOSS OF INCOME - Documentation from employer showing layoff or reduced earnings OR
furloughed letter OR check stubs noting decrease of hours/wages OR letter from employer
showing reduction in hours/ wages due to COVID-19
After you have completed the entire Arlington Cares application and collected all the required
verifications listed above, submit your application with all documentation to the Arlington Housing
Authority office located at 501 W. Sanford St, Suite 20, Arlington, TX 76011, or fax to (817) 962-1260, or
email it to homelessassistance@arlingtonhousing.us
ARLINGTON CARES ASSISTANCE APPLICATION
3 of 9 pages updated 01-27-2021
APPLICANT INFORMATION
Head of Household Last Name:
First Name:
MI:
Street Address:
City/County:
Zip Code:
Home Phone:
Cell Phone:
Work Phone:
Email Address:
Social Security #:
Emergency
Contact Name:
Address:
Phone:
If evicted, please provide address
where you currently reside:
Citizenship: U.S. Citizen Eligible Non-Citizen Ineligible Non-Citizen
Primary Language Spoken:
Marital Status of Head of Household:
Married Unmarried (widowed, single, or divorced) Married but separated
The following information is gathered to comply with federal standards
White
Native American or Native Alaskan
Native Hawaiian or Pacific Islander
and Black/White
Black/African American
Native American or Alaska Native
and White
Native Hawaiian or Pacific Islander
and Black/African American
Black/African American and
White
Native American or Alaska Native
and Black/African American
Other-Multi-Racial
Asian
Asian and White
Native Hawaiian or Pacific Islander
Ethnicity: Non-Hispanic/Non-Latino Hispanic/Latino Don’t Know/Refused
Employed: Yes No
Employer Name, Address and Phone Number:
Veteran: Yes No
Important Information for Former Military Services Members. Women and men who served in any branch of the United States Armed
Forces, including Army, Navy, Marines, Cost Guard, Reserves or National Guard, may be eligible for additional benefits and services. For
more information please visit with the Texas Veterans Portal at https://veterans.portal.texas.gov/.
ARLINGTON CARES ASSISTANCE APPLICATION
4 of 9 pages updated 01-27-2021
FAMILY INFORMATION
List Information for ALL persons in the household (including the Head of Household):
Legal Name
Sex
(M/F)
Date of
Birth
Age
Social Security
Number
Relation to
Applicant
Person has
Disability
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
ANNUAL INCOME INFORMATION
Please list gross payments (before taxes) made to each family member age 18 or older for wages, worker’s compensation, social
security, SSI, disability, welfare assistance, unemployment benefits, retirement payments, child support, military pay, periodic gifts,
barter income, and business or professional income. Include payments made to family members age 18 or older on behalf of other
family members under age 18.
Income
Head of
Household
Spouse
Other Household
Member 18 years
or older
Other Household
Member 18 years
or older
Total
Salary including OT & bonuses
Social Security/SSI/SSDI
Retirement/Pension
Child Support/Alimony
Net Income from Business
Commissions/Tips
Unemployment Benefits
Workers Compensation, etc.
TANF
Interest and/or Dividend
Gifts or Contributions
Other
Pay period: Hourly Weekly Bi-Weekly Semi-monthly Monthly Annually Other
Hours worked per week: _____________
ARLINGTON CARES ASSISTANCE APPLICATION
5 of 9 pages updated 01-27-2021
OTHER INFORMATION
1. Did you lose employment due to COVID-19? Yes No
2. Do you have lower income due to COVID-19? Yes No
When did the loss of income or lowered income happen? ________________________________________
3. Are you or is someone in your household at higher risk for COVID-19 because of age (over 65) or medical
condition? (chronic lung disease, moderate to severe asthma, serious heart conditions, immunocompromised, severe
obesity, diabetes, chronic kidney disease and undergoing dialysis, liver disease) Yes No
4. Has anyone in your household received notice that they will start receiving income? (For example, starting a
new job, starting unemployment benefits, etc.) Yes No
5. Are you currently receiving any other type of housing assistance or have you received any rental assistance
from other sources(for example, City, County, church or other organization for the months that you are
seeking assistance? Yes No
If yes, what type of housing assistance are you receiving?_______________________________________
6. Are you receiving SNAP benefits? Yes No If yes, how much? ______________________
7. If you are without a home, where have you slept in the past week? ________________________________
For rental assistance – Provide the contact information of your landlord.
8. Landlord’s name: __________________________________
9. Landlord’s contact information (email and/or phone number): ____________________________________
10. Period of Lease: ______________ to ____________ Lease start date: ______________________________
11. How much is your monthly rent? Do not include any past due rent or late fees. _________________________
12. What bedroom size apartment/rental do you have? ___________________________________________
13. What months’ rent is the last you paid in full? _________________________________________________
14. List prior, current, and future months for which you are seeking rental assistance: Note that the months of
prior, current and future months cannot exceed 6 months. ____________________________________________________
15. Do you need assistance with utilities? Yes No If yes, submit a copy of your utility bill
FOR TEXAS EVICTION DIVERSION PROGRAM CASES ONLY
Court Docket #: _____________ Justice of the Peace (J.P.) Precinct# _______ in Tarrant County
ARLINGTON CARES ASSISTANCE APPLICATION
6 of 9 pages updated 01-27-2021
ASSET INFORMATION
Please list all checking, savings, other bank accounts, held by any household member. Add additional page if needed.
Type of
Account
Account #
Current Balance
Name of Financial Institution
$
$
$
$
$
$
$
HOMELESS PREVENTION /HOMELESS ASSISTANCE
I reside in Arlington, Texas
I have received written notice or letter of eviction from the court or my landlord
I have no resources or support network to prevent homelessness
I am not homeless now, but have previously experienced homelessness
Please provide the reason(s) that you have not and are unable to pay your rent and/or utilities:
If you are assisted with payment of your delinquent rent and utility bills, please identify how you will be able
to pay your rent / utilities on going forward basis.
I understand that applicants approved may voluntarily agree to participate in case management services. I hereby
certify that the information I have provided herein is true, complete, and correct.
Printed Name of Applicant
________________________________________________
Signature of Applicant Date
ARLINGTON CARES ASSISTANCE APPLICATION
7 of 9 pages updated 01-27-2021
Please check the box that describes your circumstances.
1. An individual or family who lacks a fixed, regular, and adequate nighttime residence, meaning:
a. An individual or family with a primary nighttime residence that is a public or private place not
designed for or ordinarily used as a regular sleeping accommodation for human beings, including a
car, park abandoned building, bus or train station, airport, or camping ground; or
b. An individual or family living in a supervised publicly or privately operated shelter designated to
provide temporary living arrangements; or
c. An individual who is exiting an institution where he or she resided for 90 days or less and who resided
in an emergency shelter or place not meant for human habitation immediately before entering that
institution.
2. An individual or family who will imminently lose their primary nighttime residence, provided that:
a. The primary nighttime residence will be lost within 14 days of the date of application for homeless
assistance; and
b. No subsequent residence has been identified; and
c. The individual or family lacks the resources or support networks needed to obtain other permanent
housing.
3. Unaccompanied youth under 25 years of age, or families with children and youth, who do not otherwise
qualify as homeless under this definition, but who:
a. Are defined as homeless under other federal programs as described in 24 CFR 576.2; or
b. Have not had a lease, ownership interest, or occupancy agreement in permanent housing at any time
during the 60 days immediately preceding the date of application for homeless assistance; or
c. Have experienced persistent instability as measured by two moves or more during the 60 day period
immediately preceding the date of applying for homeless assistance; AND
d. Can be expected to continue in such status for an extended period of time because of chronic
disabilities, chronic physical health or mental health conditions, substance addiction, histories of
domestic violence or childhood abuse, the presence of a child or youth with a disability, or two or
more barriers to employment, which include the lack of a high school degree or GED, illiteracy, low
English proficiency, a history of incarceration or detention for criminal activity, and a history of
unstable employment; or
4. Any individual or family who:
a. Is fleeing, or is attempting to flee, domestic violence, dating violence, sexual assault, stalking, or other
dangerous or life-threatening conditions that relate to violence against the individual or family
member, including a child that has either taken place within the individual’s or family’s primary
nighttime residence or has made the individual or family afraid to return to their primary nighttime
residence; and
b. Has no other residence; and
c. Lacks the resources or support networks to obtain other permanent housing.
Printed Name of Applicant Date
________________________________________________
Signature of Applicant
HOMELESS ASSISTANCE / HOMELESS PREVENTION
ARLINGTON CARES ASSISTANCE APPLICATION
8 of 9 pages updated 01-27-2021
RELEASE AND CONSENT FORM
I/We _____________________________________________________, the undersigned hereby authorize all
persons or companies in the categories listed below to release information regarding tenancy, employment,
income and/or assets for purposes of verifying information on my/our application for participation in the
Arlington CARES Rental Assistance I/we authorize release of information without liability to the Arlington
Housing Authority/City of Arlington.
INFORMATION COVERED
I/We understand that previous or current information regarding me/us may be needed. Verifications and
inquires that may be requested include, but are not limited to: personal identity, student status, employment,
income, assets, tenancy, and medical or child care allowances. I/We understand that this authorization cannot
be used to obtain information about me/us that is not pertinent to my eligibility for and continued
participation in a Arlington CARES Rental Assistance .
GROUPS OR INDIVIDUALS THAT MAY BE ASKED
The groups or individuals that may be asked to release the above information include, but are not limited to:
Past and Present Employers Welfare Agencies Veterans Administrations
Support and Alimony Providers State Unemployment Agencies Retirement Systems Educational
Institutions Social Security Administration Medical and Child Care Providers
Bank and other Financial Institutions Utility Providers Previous/current Landlords
Public Housing Agencies Appraisal Districts Insurance Carrier
Justice of the Peace (JP)
APPLICANT CERTIFICATION
I/We agree that a photocopy of this authorization may be used for the purposes stated above. The original of
this authorization is on file and will stay in effect for a year and one month from the date signed. I/We
understand I/We have a right to review this file and correct any information that is incorrect.
____________________________ ____________________________ _______________________
Applicant/Resident Printed Name Signature Date
_____________________________ ____________________________ _______________________
Co-Applicant/Resident Printed Name Signature Date
_____________________________ ____________________________ _______________________
Adult Member Printed Name Signature Date
_____________________________ ____________________________ _______________________
Adult Member Printed Name Signature Date
NOTE: THIS GENERAL CONSENT MAY NOT BE USED TO REQUEST A COPY OF A TAX RETURN. IF A COPY OF A
TAX RETURN IS NEEDED, IRS FORM 4506, “REQUEST FOR COPY OF A TAX FORM” MUST BE PREPARED AND
SIGNED SEPARATELY.
ARLINGTON CARES ASSISTANCE APPLICATION
9 of 9 pages updated 01-27-2021
I, the undersigned, do hereby certify that the information provided above is complete, true and correct to the
best of my knowledge, and I do hereby authorize the staff of the Arlington Housing Authority to verify the
information included in this application to approve eligibility by whatever means necessary, including but not
limited to wages, pensions, investments, and residency. I further certify that this property is not owned or
managed by a blood relative or a relative by marriage.
It is understood that this authorization is granted for the sole purpose of certifying eligibility for the Arlington
Housing Authority, and that all information acquired in this regard will remain confidential.
I also understand that if my application is denied for any reason, I may request an appeal.
I acknowledge that, I will be required to pay back any funds awarded under this application if it is later found
that I or my landlord received duplicate assistance.
Printed Name of Applicant
_______________________________________________
Signature of Applicant Date
WARNING: It is a criminal offense to make willful false statements or misrepresentations to any
department or agency of the United States Government as to any matter within its jurisdiction (Section
1001 of Title 18, U.S. code)
---------------------------------------For Office Use Only---------------------------------------
CDBG (80% AMI)
CDBG- CARES (80% AMI)
TERAP (80% AMI)
TERAP (60% AMI)
ESG- CARES (50% AMI)
EHA (120% AMI)
HHSP (30% AMI)
HHSP – CARES (30% AMI)
EHAP – CARES (80% AMI)
_______________________________________________
Staff Signature Date
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The CARES Act and other available funding through (City of Arlington, Texas)

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Completed 13 February 2021

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