NY United Screening Form

SCREENING ADMINISTRATOR INFO

Organization

Staff Member first name

Staff Member last name

Staff Member email

Staff Member phone

COMMUNITY MEMBER INFO (APPLICANT)

Full name

Telephone number

Street Address

City

State

ZIP Code

Eligibility Criteria

Please complete and submit this information for each eligible community member to whom your organization wishes to issue an NYIC NY United debit card.

Community member lost paid work/income due to COVID-19 (e.g. lost job, reduced hours).

YesNo

Community member has increased financial needs due to the COVID-19 pandemic (e.g., lost paid work/income, childcare expenses, medical expenses)

YesNo

Screening (continued)

Community member meets at least one of the following eligibility criteria:

Is ineligible for the Federal CARES Act stimulus paymentIs ineligible for SNAPIs ineligible for Unemployment InsuranceDoes not have direct deposit on file with IRSMain source of income is/was cash tipsNone of the above

Community member meets at least one of the following eligibility criteria:

Is ineligible for the Federal CARES Act stimulus paymentIs ineligible for SNAPIs ineligible for Unemployment InsuranceMain source of income is/was cash tipsNone of the above

Community member connection to New York City (please select all that apply):

NYC ResidentWorks in NYCAttends school in NYCImmigration court case docketed in NYCHad to move out of NYC due to COVID-19Classes were canceled in NYC due to COVID-19Lost work in NYC due to COVID-19None of the above

Is the community member a resident of New York State who lives OUTSIDE of New York City?

YesNo

Has the community member received a cash grant from another nonprofit/CBO's COVID-19 relief fund?

YesNo

Card Information & Attestation

Based on your form responses, this community member is eligible for an NYIC NY United debit card. Kindly supply the following information to proceed.

Select the email of the designated reviewer, who will receive a notification to submit final approval.

Reviewer

Please check the box below before submitting this screening form.

I attest that, based on the information provided to me by this individual (including any information contained in client files, if relevant), they are eligible to receive funds through this program.

Screening Administrator - Enter your initials:

Date

Based on your form responses, this individual is not eligible for funding through the fund.