Applicant Information
Homelessness Crisis
Harford County Continuum of Care Consent to Participate Homeless Management Information System (HMIS) and CAP60
The Harford County Continuum of Care administers a computerized record keeping system that captures information about people experiencing homelessness, including their service needs. This agency uses HMIS and CAP60 as their data management tools to collect information on the clients they serve and the services they provide. The HMIS system benefits you because you may not have to complete an additional intake interview should you need services from a collaborating agency that also uses HMIS. The information shared with one or more collaborating agencies will be used to help you access services such as emergency assistance, shelter, and transitional housing. Your written consent allows this agency to share your intake information with other collaborating agencies to better serve you. The information that you share with this agency will be used to help you access services that will help you obtain and maintain permanent housing. The information that you provide, combined with that provided by others, will be used, without any identifying information, for reporting requirements and advocacy. This agency has an interagency sharing agreement with several collaborating agencies regarding individuals that are served by both agencies. These agencies also have an agreement with the Harford County Continuum of Care and have completed security procedures regarding the protection and sharing of your data. These agencies may also use your information, without any identifying information, for reporting requirements and advocacy. Harford Community Action Agency (HCAA) uses CAP60, a database designed to provide a comprehensive set of resources to our program participants. We use this system to communicate internally and provide referrals to other programs for which you may qualify. We also use referral forms to guide agency staff in best assisting you beyond a single department. Additionally, we work with outside agencies to present additional service options to each household with whom we work.
to have information (demographic, residential, employment, income, military, legal, services, and goals and outcomes) that I provided in intake interviews to staff at Harford Community Action Agency to be shared electronically with other departments within the Agency and with collaborating agencies in the Continuum of Care for use in providing comprehensive services
MEDICAL, MENTAL HEALTH and SUBSTANCE USE HISTORY SHARING AUTHORIZATION
to have information (medical, mental health, and substance use history) that I provided in intake interviews to staff at Harford Community Action Agency to be shared electronically with other departments within the Agency and with collaborating agencies for use in providing the most comprehensive services possible. Agencies are responsible for being aware of HIPAA compliance and federal regulations governing Confidentiality and Drug Abuse Patient Records (42 CFR part 2), and the Maryland Confidentiality of Medical Records Act (MCMRA) when sharing information.
Housing
Information on race is being collected to ensure compliance with fair housing and equal opportunity rules.
Additional Household Member #1
Additional Household Member #2
Additional Household Member #3
Additional Household Member #4
Additional Household Member #5
Additional Household Member #6
Additional Household Member #7
Additional Household Member #8
Hunger Prevention
Supplemental Food
Food Pantry - Self Declaration of Income
We will not need supporting documentation to provide food from the Food Pantry, but we do need a Self-Declaration of Income statement (below)
Check (√) if NO INCOME for your household applies below:
PLEASE REPORT GROSS INCOME (BEFORE TAXES AND INSURANCE) Please identify all types of household income per month:
• I swear (or affirm) that all information on this declaration is true, correct and complete to the best of my ability, knowledge and belief.
• I give permission to Harford Community Action Agency to check all household income and any other benefits indicated with other governmental and non-governmental agencies for verification purposes as well as share information to complete this application for services. Maryland has a fraud law. Punishment can occur for not telling the truth when applying for assistance.
• I understand that I will be penalized my fine and/or imprisonment for giving false statements.
Completing this form makes this statement binding
SNAP (Food Stamps) Application Assistance
Consent for Release of Information
This form authorizes information to be released from the Local Department of Social Services to the Community Based Organization and Customer. I hereby authorize the Family Investment Administration to release all information contained in, and concerning the status of, my application/redetermination for Public benefits, as a resident of the State of Maryland, to Harford Community Action Agency This information may be released to the following person (s): Kim Neely - Supervisor; Roxanne Burton, Sonia Harrison, Tara Phillips - Staff
NOTE: You will be required to provide supporting documentation to determine eligibility. Upon completion of this form, you'll be directed to a page where you can upload your documents. An email/text will also be sent to you, with a link to that page, in case you need to gather your documents together first.
Do you need assistance paying your energy bills?
Assistance with Energy Bills
ELECTRIC GRANT - Electric Universal Service Program (EUSP)
HEATING GRANT - Maryland Energy Assistance Program (MEAP)
PAST-DUE ELECTRIC BILLS - Arrearage Retirement Assistance (ARA)
PAST-DUE GAS BILLS - Gas Arrearage Retirement Assistance (GARA)
ENERGY EFFICIENCY FOR YOUR HOME – DHCD Energy Efficiency Programs
NOTE: You will be required to provide supporting documentation to determine eligibility. Upon completion of this form, you'll be directed to a page where you can upload your documents. An email/text will also be sent to you, with a link to that page, in case you need to gather your documents together first.
Do you need assistance paying your rent due to COVID-related Hardship?
Assistance with Rent Bills
By completing this application, I/we authorize Harford Community Action Agency and its representatives to speak with my/our Landlord and with whomever has information necessary to process our rental assistance application.
Harford Community Action Agency agrees to maintain the confidentiality of tenant's information; however; I/we also authorize Harford Community Action Agency to submit my/our personal information to the entities funding this program or their agents for the exclusive purposes of program evaluation and monitoring.
Tenant Information
Landlord Information
NOTE: You will be required to provide supporting documentation to determine eligibility. Upon completion of this form, you'll be directed to a page where you can upload your documents. An email/text will also be sent to you, with a link to that page, in case you need to gather your documents together first.
Potential Barriers to Housing
Rental History
Credit History
Criminal History
Personal Barriers
Chemical Health
Mental Health
Domestic Violence / Abuse
Physical / Medical Condition
Income Barriers
Client Agreement
I declare that the information I have provided Harford Community Action Agency (HCAA) is true, correct and complete. I understand that when this application is signed, permission is given to the HCAA to check all household income, bank accounts, housing expenses, insurance, and other benefits. If I currently receive or have ever received benefits from the programs administered by the Harford County Department of Social Services (DSS), by signing this application, I give permission to the DSS to share with HCAA any information in my DSS case file needed to complete this application. Such information includes, but is not limited to, household members, income, expenses, resources, child support payments, etc. I acknowledge that my application information will be stored digitally in the agency database: CAP60. This information will be maintained with the utmost confidentiality, and only HCAA staff will have access to individual files within the database. Maryland has a fraud law. Punishment can occur for not telling the truth when applying for assistance from any HCAA program. Harford Community Action Agency, Inc. prohibits discrimination in all its programs and activities on the basis of race, color, national origin, sex, religion, age, disability, political beliefs, sexual orientation, or marital or family status.
By signing this form, you acknowledge that you have read, understand and agree to abide by our eligibility requirements, rights and responsibilities. To assure the safety of all clients and staff, HCAA has the right to refuse services to households who happen to engage in behavior that can be defined under the following: Any threats, abusive language or behavior, or any other disruptive behavior (inappropriate gestures or comments, verbal abuse, intimidation, etc.) may be grounds for immediate exit from HCAA programs and future assistance. NOTE: Joking about violence of any sort is considered inappropriate and will not be tolerated.
Grievance Process:
If the client wishes to file a grievance, they may do so in writing to the Executive Director stating the situation and their concerns. The Executive Director must set up an appointment with the client within 14 days of receipt of the letter of grievance to discuss the grievance and reach a solution. The client may speak to the Executive Director or Assistant Director, if available, during their application process.