CHN Housing Partners Family Stability Initiative Application

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Please use the page numbers above to navigate to specific areas of the form

Welcome to CHN Housing Partners Online Application for Family Stability Initiative

How does it work?

This lifeline, funded by the Siemer Institute and United Way of Greater Cleveland, is for families with school-aged children that need help maintaining or obtaining stable housing.

Note: We can provide up to $1500 of rental assistance for rent payments and/or security deposits.

Online Application Guidelines

To apply for programs with CHN Housing Partners, you must complete an application with us along with providing documents to verify the information submitted. We have split this into the following sections:

1. Application information: Your contact and demographic information

2. Household members: Other members of your household and their demographic information

3. Income sources: All sources of income and public benefits for all household members over 18

4. Assets: All liquid assets for all household members over 18

5. Housing & utility details: Details about your rent/mortgage and utilities for program-specific purposes and to help us assess what program(s) you may need

6. Document upload: We will request scanned copies, legible photos or screenshots of documents as verification for your eligibility for programs.

You may encounter a slow system or downtime due to a high volume of traffic on the site. Please use the "Save my progress and resume later" feature located at the top of the form OFTEN to avoid losing any information. (This form is powered by FormAssembly.)

Fair Housing Act (42 USC 3600, et seq.)

If you have an impairment, disability, language barrier, or otherwise require an alternative means of completing this form or accessing information about our services, please talk to us about arranging alternative accommodations. We serve all clients regardless of income, race, color, religion/creed, sex, national origin, age, family status, disability, or sexual orientation/gender identity. We administer our programs in conformity with local, state, and federal anti-discrimination laws, including the federal Fair Housing Act (42 USC 3600, et seq.)

Click Next Page to Continue

If a referral agency is completing this application on behalf of a client, please provide your name and contact information so that we can contact you upon receipt.

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Applicant and Co-Applicant Details

In this section, please enter your most up to date contact information and demographic information.

CHN Housing Partners (CHN) is committed to assuring the privacy of individuals and/or families who have contacted us for assistance. We realize that the concerns you bring to us are highly personal in nature. We assure you that all personal information shared verbally and/or in writing will be managed within ethical and legal consideration. Additionally, we want you to understand how we use the personal information we collect. Please carefully review this notice as it describes our policy regarding the collection and disclosure of your nonpublic, personal information.

CHN's Housing Counseling Disclosure and Privacy Policy

The Applicant (and Co-Applicant, if applicable) should be an adult member of your household that will be able to represent, provide information for, and make decisions on behalf of your household.

Please prepare for upload: Photo Identification and Social Security Cards for each Applicant and Co-Applicant.

Applicant Information

Applicant first name

Applicant last name

Applicant home phone

Applicant cell phone

Applicant email address

Re-enter email address

Confirmation

Applicant Social Security number

Confirm Social Security Number

Confirmation

Applicant mailing street

Applicant city

Applicant state

Applicant zip code

Applicant primary language

Applicant gender

Applicant birthdate

Enter date in MM/DD/YYYY format

Applicant marital status

Applicant race

Applicant ethnicity

Applicant highest education

Applicant disabled

Applicant military status

Applicant citizenship status

Applicant driver's license number

How did you hear about us?

Referral Agency

Please select the Agency that helped you complete this Application or made you aware of it

Other Referral Agency

Is there a Co-Applicant?

YesNo

Co-Applicant Information

Co-Applicant first name

Co-Applicant last name

Co-Applicant cell phone

Co-Applicant email address

Co-Applicant Social Security number

Confirm Social Security number

Confirmation

Co-Applicant primary language

Co-Applicant gender

Co-Applicant birthdate

Enter date in MM/DD/YYYY format

Co-Applicant marital status

Co-Applicant race

Co-Applicant ethnicity

Co-Applicant highest education

Co-Applicant disabled

Co-Applicant military status

Co-Applicant citizenship status

Co-Applicant driver's license number

WARNING: The information provided on this form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.

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Household Members

Please enter additional members who reside in your household (i.e. children, dependents, other family members, etc.). Use the "Add Additional Household Member" link to add as many as you need.

You do not need to re-enter Applicant or Co-applicant (if applicable) information here.

Please prepare for upload: For each household member, be prepared to provide verification that they are your dependents - such as Social Security Cards and Birth certificates

Do you have Additional Household Members to report?

YesNo

Household Member

Full name

Birthdate

Enter date in MM/DD/YYYY format

Social security #

Gender

Disabled

Race

Ethnicity

Education attainment

Employment status

Citizenship status

Currently attending school?

YesNo

Name of school

Grade

WARNING: The information provided on this form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.

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Current Income Sources and Public Benefits

Please enter all sources of Income and Public Benefits that the household is CURRENTLY receiving, for all household members over the age of 18.

Use the "Add Additional Income Source" link to add as many as you need

Current Annual Income is the estimated income for the current year including any wages,

benefits, alimony, child support and other forms of financial income or support.

Income includes: Full-time employment, part-time employment, self-employment, spousal support, child support, investment income, Social security, SSI, SSDI, income from assets, pension/annuity, unemployment, adoption subsidy, short term disability, long term disability, veteran's benefits, zero income, family contribution, other

Public benefits include: Food stamps, WIC, ADC, OWF/TANF, rental subsidy, utility allowance, other public benefit

Please prepare for upload: Verification of income for the past 30 days - pay stubs, employment letters, award letters, etc.

Do you have Current Income to report?

YesNo

Current Income or Public Benefit Source

Income earner's name

Enter the Household Member who this income belongs to

Income / Benefit type

Job title

Provide the Job Title for Employment types, if applicable

Please take the total income you received in the last 30 days and multiply by 12 to determine your annual income:

Current annual income amount

Please estimate to the best of your ability. Our staff will review your documents and provide a full eligibility determination.

WARNING: The information provided on this form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.

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Assets Declaration
Please enter all liquid Assets you have control over for all household members over the age of 18. Liquid assets are cash on hand or assets in any other form that can be converted to cash within 20 days (SSA.gov)

Asset types include: Bank Accounts - Savings and/or Checking, Investment Accounts, Retirement, Certificates of Deposit, Cash on Hand, Pre-paid Debit Cards, Health Savings Accounts, Life Insurance Cash Value

Do you have Assets to report?

YesNo

Asset

Asset Type

Value

Please estimate to the best of your ability - enter 0 if unsure

WARNING: The information provided on this form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.

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Upload Documents

Please use this page to upload documents that support your application. You can attach electronically downloaded documents, use a scanner, or take pictures or screenshots of your documents with your phone.

You can upload multiple files per section by using the "Add another ..." link. There is a limitation of 20 files per form. If you have more than 20 files to upload, please email them to info@neorenthelp.org.

Gather the required documents:
1. Photo identification for all household members 18 years or older
2. Verification of household members (Social Security card preferred, or birth certificate) for all household members
3. Lease (which can be obtained from landlord if not available to tenant)

Complete applications with all required supporting documents will be processed faster - please upload as much as you are able to and ensure you have documents for each section!

Photo identification & Social Security cards

If taking photos with your phone/camera, you can line up your IDs and Social Security cards within one image, instead of one at a time

Lease Agreement

Upload a copy of your current Lease Agreement or Lease Template (required, if available, we can also retrieve from your landlord)

Lease

Income Documents for Utility Assistance

Utility Bills

Upload Utility Bills in each section listed here based on programs you are requesting assistance for.

Electric Bill

Gas Bill

Water Bill

Sewer Bill

Do you have other supporting documents to upload?

YesNo

Other Documents

WARNING: The information provided on this form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.

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Acknowledgement & Submit

I/we certify that all provided information is correct to the best of my knowledge and have received a copy of CHN's Housing Counseling Disclosure and Privacy Policy. I/we authorize CHN Housing Partners to verify all information contained on this online form and to pull my credit report. I/we understand that I may be assisted by federal funds which carry severe penalties, including incarceration.

CHN's Housing Counseling Disclosure and Privacy Policy

By typing my full name below, I hereby authorize CHN to release nonpublic personal information it obtains about me to any third parties necessary to provide me with the services I requested. I acknowledge that I have read and understand the above privacy practices. I understand I will receive a copy of all information submitted at the email address I provided on Page 2, "Applicant E-mail Address".

WARNING: The information provided on this form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.

Applicant signature

Co-Applicant signature

Applicant acknowledgement date

Co-Applicant acknowledgement date

If you are a referral agency submitting this application on behalf of a client, please provide your name and contact information below so that we can confirm receipt.