Project Hope

Application

A transitional, faith-based, supportive housing program
for single women with children.

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Are you homeless?(Required)
Have you ever applied for this program before?

PERSONAL INFORMATION

Ever received services under different name?
If yes, then provide:
Marital Status
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U. S. Citizen
(You must have a valid Florida Driver’s License or State ID to be considered for the PH program)
Current Mailing Address
Race(Please pick at least one racial designation, choose all that apply):
Military Status:
servedin U.S. Military (veteran):
Before 2002
Will you need any accommodations to participate in this program?

CURRENT HOMELESS STATUS:

Where did you stay last night (choose one):
If you are currently housed, are you being evicted within 30 days?
Where did you stay before last night?(
Total number of times homeless (including this time - choose one):
Number of times homeless in the past five years (choose one):
How long have you been homeless this time?(choose one):
Reasons or contributing factors to homeless situation (s)(may check more than one):

Tell us about your last permanent address(where you last lived for 90 days or more):

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This address is:
Please list all states that you have lived in since the age of 18:
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EMPLOYMENT:

Currently Employed:
Type of Work:
If not employed, are you looking for work:
If not employed, how long did you work on last job:
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Income from work & other sources:
Received Income From Work Last Month
Income received from other sources

Non-Cash Benefits

Food Stamps
Medicaid Health Insurance
Medicare Health Insurance
Florida Kid Care
Women Infants Children (WIC)
Veteran’s VA Medical Services
CDS - Child Care Services
Rental Assistance, Section 8, Housing Vouchers

EDUCATION:

Are you in school now:
Working on a degree/certification:
Do you have a vocational or apprenticeship certificate
Highest level of education completed (choose one):
Received Degrees (choose all that apply):
CHILDREN (for minors up to age 17):
Total number of children:
If child(ren) is/arebetween ages 4-17and not in school explain why(may check more than one):
If younger than age 4, why not in daycare (may check more than one):
Do you or the other parent have visitation rights?
Have you ever been investigated for child abuse and/or neglect:
If yes, list dates

DOMESTIC VIOLENCE:

Experienced Abuse:
If Current or Past, How Recent:
Is there a current safety concern:

HEALTH INFORMATION:

General Health (choose one):
Currently Pregnant:
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(MM/DD/YYYY)

DRUGS:

Have you ever used drugs?
Have you ever been in a drug treatment program?
Have you ever been arrested for any drug related offenses?

SUBSTANCE USE:

e. Has your drinking caused any problems for you?
Have you ever been arrested for any alcohol related driving offenses?
Have you ever been in an alcohol treatment program?

CRIMINAL BACKGROUND:

Have you ever been arrested or ever been charged with a Felony?
Are you currently involved in any court/legal proceedings?

ANSWER THE FOLLOWING QUESTIONS IN DETAIL(attach an additional sheet if necessary):

What steps have you taken, so far, to prevent you from becoming homeless?

Once you obtain housing, what are your:

EMERGENCY CONTACT:

Address

REFERENCES

(List people, unrelated to you, who we can contact for references.)
Personal/Professional Reference:
Address

Personal/Professional Reference:

Address

Personal/Professional Reference:

Address
I give Project Hope permission toCONTACT ALL REFERENCES &run a CRIMINAL BACKGROUND CHECK (see pages13& 14 Fair Credit Reporting Act). I understand that if I fail to provide written permission, my application will not be processed. I further understand that I have been provided a copy of the agencies Privacy Practices and have read and understand them.
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Check ALL that Apply

ATTEST OF INFORMATION

I attest that all the information provided in this application is honest and accurate to the best of my knowledge. I understand that any deliberate misrepresentation of the information could result in my being denied acceptance into or expelled from transitional housing.
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Please CompleteALL12pages to include Fair Credit Reporting Act & CMIS Reprogram agreement. Incomplete or illegible applications will be returned. Return completed application to: Project Hope * 830 NE 28th St. #201 * Ocala, FL 34470

All applicants are to be assured of confidential treatment of personal information to the extent possible. Project Hope shall obtain written permission from the program participant in agreement of information to be releases, unless such program agreement is otherwise authorized by law.

Address & Employment History

List the places you have resided in the past 5 years.

1. Address

Dates resided

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Within city limits of Ocala, Florida
2. Address

Dates resided

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Within city limits of Ocala, Florida
3. Address

Dates resided

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4. Address

Dates resided

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5. Address

Dates resided

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6. Address

Dates resided

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7. Address

Dates resided

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List the places you have been employed in the past 5 years.

Present Employer:
Address
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1. Previous Employer

Address
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2. Previous Employer:

Address
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3. Previous Employer:

Address
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4. Previous Employer:

Address
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5. Previous Employer:

Address
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Project Hope of Marion County

Consent to Program Agreement Information

If you consent, we have the ability to share your information with our collaborating entities to be used for intake assessment. You can choose to share all or part of the information that you have submitted including basic demographic information, residential, employment skills/income, military/legal, service needs, goals, and outcomes. This cannot take place unless you provide written consent by signing and dating this Consent to Reprogram Agreement Information. No medical, mental health or substance use history will be shared unless you provide express written consent. Your information and information contained on the application about other residents will be shared for a period of no more than 4 years from today’s date.

authorize Project Hope to disclose to appropriate entities any information regarding my general condition, past and present, and/or information about other family members or other residents contained in the application concerning services provided to and/or required by me and others I have listed on the application. This consent may be revoked by me or any other family member or resident, at any time except to the extent that action has been taken in reliance thereon. This consent unless expressly revoked earlier will expire four years from the date indicated below. I declare that the information I give is true and correct to the best of my knowledge.
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FAIR CREDIT REPORTING ACT

DISCLOSURE AND AUTHORIZATION

Disclosure: In order to evaluate your application for Project Hope’s Transitional Housing Program or, if accepted, to assist management with decisions, Project Hope may obtain consumer reports, investigate consumer reports and criminal history records check regarding you. These reports are any information from a consumer reporting agency bearing upon your credit history, character, reputation, personal characteristics, medical information, or mode of living which is used or collected for the purpose of informing any decision regarding your prospective or actual program relationship.

You have certain rights regarding these reports and their use as defined under the Fair Credit Reporting Act and as summarized in “A Summary of Your Rights under the Fair Credit Reporting Act” which has been provided to you.

Authorization: I voluntarily authorize Project Hope to obtain consumer reports, investigative consumer reports and criminal history records check about me in order to make informed decisions regarding my proposed or actual program relationship with Project Hope. The information obtained may include medical information. I acknowledge that I have rights under the Fair Credit Reporting Act including those discussed in “A Summary of Your Rights under the Fair Credit Reporting Act” which I have received and reviewed.

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Gender

A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT

The federal Fair Credit Reporting Act (FCRA) is designed to promote accuracy, fairness, and privacy of information in the files of every “consumer reporting agency” (CRA). Most CRA’s are credit bureaus that gather and sell information about you – such as if you pay your bills on time or have filed bankruptcy – to creditors, employers, landlords, and other businesses. You can find the complete text of the FCRA, 14 U.S.C. 1681-1681 u et seq., at the Federal Trade Commission’s web site (http://www.ftc.gov) The FCRA gives you specific rights, as outlined below. You may have additional rights under state law. You may contact a state or local consumer protection agency or a stated attorney general to learn these rights.

• You must be told if information in your file has been used against you. Anyone who uses information from a CRA to take action against you – such as denying an application for credit, insurance, or employment – must tell you, and give you the name, address, and phone number of the CRA that provided the consumer report.

• You can find out what is in your file. At your request, a CRA must give you the information in your file, and a list of everyone who has requested it recently. There is no charge for the report if a person has taken action against you because of information supplied by the CRA, if you request the report within 60 days of receiving notice of the action. You are also entitled to one free report every twelve months upon request if you certify that (1) you are unemployed and plan to seek employment within 60 days, (2) you are on welfare, or (3) your report is inaccurate due to fraud. Otherwise, a CRA may charge you up to eight dollars.

• You can dispute inaccurate information with the CRA. If you tell a CRA that your file contains inaccurate information, the CRA must investigate the items (usually within 30 days) by presenting to its information source all relevant evidence you submit, unless your dispute is frivolous. The source must review your evidence and report its finding to the CRA. (The source must also advise national CRAs – to which it has provided the data – of any error). The CRA must give you a written report of the investigation, and a copy of the report, if the investigation results in any change. If the CRA’s investigation does not resolve the dispute, you may add a brief statement to your file. The CRA must normally include a summary of your statement in future reports. If an item is altered or a dispute statement is filed, you may ask that anyone who has recently received your report be notified of the change.

• Inaccurate information must be corrected or deleted. . A CRA must remove or correct inaccurate information from its files, usually within 30 days after you dispute it. However, the CRA is not required to remove accurate data from your file unless it is outdated or cannot be verified. If your dispute results in any change in your report, the CRA cannot reinsert into your file a disputed item unless the information source verifies its accuracy and completeness. In addition, the CRA must give you a written notice telling you it ahs reinserted the item. The notice must include the name, address and phone number of the information source.

• You can dispute inaccurate information items with the source of the information. If you tell anyone – such as a creditor who reports to a CRA – that you dispute an item, they may not then report the information to a CRA without including a notice of your dispute. In addition, once you’ve notified the source of the error in writing, it may not continue to report the information if it is, in fact, an error.

• Outdated information may not be reported. . In most cases, a CRA may not report negative information that is more than seven years old; ten years for bankruptcies.

• Access to your file is limited. A CRA may provide information about you only to people with a need recognized by the FCRA – usually to consider an application with a creditor, insurer, employer, landlord, or other business.

• Your consent is required for reports that are provided to employers, or that contain medical information. A CRA may not give out information about your to your employer, or prospective employer, without your written consent. A CRA may not report medical information about you to creditors, insurers, or employers without your permission.

• You can choose to exclude your name from CRA lists for unsolicited credit and insurance offers. Creditors and insurers may use file information as the basis for sending your unsolicited offers of credit or insurance. Such offers must include a toll free number for you to call if you want your name and address excluded from future lists. If you call, you must be kept off the lists for two years. If you request, complete and return the CRA form provided for this purpose, you must be taken off the lists indefinitely.

• You may seek damages from violators. If a CRA, a user or (in some cases) a provider of CRA data, violated the FCRA, you may sue them in state or federal court.