2020 Poverty Guidelines 48 Contiguous States and D. C - Persons in Household

Page created by Gilbert Delgado
 
CONTINUE READING
2020 Poverty Guidelines
        48 Contiguous States and D. C.
Persons in   200% Poverty Guideline   200% Poverty Guideline
Household          (Monthly)                (Yearly)
    1               $2,127                   $25,524
    2                $2,873                  $34,476
    3                $3,620                  $43,440
    4                $4,367                  $52,404
    5                $5,113                  $61,356
    6                $5,860                  $70,320
    7                $6,607                  $79,284
    8                $7,353                  $88,236
SOCIAL SECURITY NUMBER
                                        Economic Opportunity Council of Suffolk, Inc.                                                                 Número de seguro social

                                                     31 West Main Street  3rd Floor Ÿ Suite 300
                                                                   Patchogue, New York 11772                                                          DATE OF
                                                                                                                                                      INTAKE
                                                Telephone: (631) 289-2124  Fax: (631) 289-2178                                                       Fecha de entrada
Name (Last, First, M.I.) Nombre (Apellido, Primer, Segundo nombre de pila (marca con inicial))                                                         TELEPHONE NUMBER                                             AGE Edad
                                                                                                                                                       Número de teléfono
                                                                                                                                                       (    )                                                       0-5                45-54
Street Address (Dirección de calle y número)                                                                                                                      DATE OF BIRTH                                     6-13               55-59
                                                                                                                                                                Fecha de nacimiento                                 14-17              60-64
                                                                                                                                                                                                                    18-24              65-74
                                                                                                                                                                          /             /                           25-44              75 + OVER/más
CITY,STATE, ZIP (Ciudad, Estado, Código postal)                                                                                                       GENDER/ Género
                                                                                                                                                                   Male/Masculino                           DISABILITY/ Discapacidad

                                       AMOUNT OF                                          TYPE OF CONTACT                    Walk-in                               Female/Femenino                                  YES/Sí
NUMBER IN HOUSEHOLD                                             ID PROVIDED
                                                                                          Tipo de contacto
   Número en hogar                   INCOME Ingresos           ID proporcionada                                              Telephone/Teléfono                    Transgender/Transgénero                          NO
                                                   /YR.                                                                      Referral-Referido                     Other - otro
                                                                                                                                                                   Unknown/not reported
                                                                                                                                                                   Deconocido /No informado

             RACE /Raza                ETHNICITY /Origen étnico                    HOUSEHOLD TYPE/Tipo de hogar                                        EDUCATION /Educación                               STATUS / Estado serológico

B- Black/African American               Hispano/latino                      F- Single Parent/Female - Monoparental/Mujer                         A-   0-8                                                           HIV+(Not AIDS)
       Raza negra or afroamericano      No hispano/latino                   M- Single Parent/Male - Monoparental/Hombre                          B-   9-12 non graduate No titulado                                 VIH+ (No sida)
W- White /Blanco                        Unknown/Deconocido                  T- Two parent Household /Hogar de dos padres                         C-   High school Diploma/GED                                       HIV+(AIDS Unknown)
M- Multi-race /Multirracial                                                 S- Single Person /Persona soltera                                    D-   12 + post secundaria                                          VIH+ (SIDA deconocido)
A- Asian /asiático                                                          A- Two Adults/ No children - Dos adultos /No niños                        E- 2/4 yr. College grad - 2/4 años.                           AIDS/ SIDA
O- Other /Otro                                                              O- Other /Otro                                                                 Graduado de la universidad
N-   Native Hawaiian/American                                               N- Nonrelated adults w/children/Adultos no relacionados con niños    G- Graduate / graduado- post secundaria                 Month         Year             Diagnosis
Indian/Alaskan Native- Indigena                                             M- Multi-generational /Hogar multigeneracional                       F- Unknown/Deconocido                                   (Mes)        (Año)          (Diagnóstico)
hawaiano o nativo de la Polinesia

                              HOUSING                                              SOURCE OF INCOME                                                   OTHER INCOME                                           MODE OF /Modo de
                               Vivienda                                            Tipo de Ingresos                                                   Otros Ingresos                                      TRANSMISSION /Transmisión
     O- Own /Dueño de casa                  Permanent/Permanente            E- Employment Full Time/empleado tiempocompleto                      S- SNAP Pro. de Asistencia Nutricional Suplementaria               Men with Men/hombre con hombre
     R-  Rent /Alquilar                    Other Permanent/otro             EP- Employment Part-Time /Empleado a tiempo parcial                  A- Alimony/ Pensión alimenticia
                                                                                                                                                                                                                    Hemophilia/hemofilia or Coag.
     H-  Homeless /Sin hogar                Institution /Institución        U- Unemployment /Desempleo (Menos de 6 meses)                        W- Workmen's Comp/Compensación de tra.                             Disorder/trastorno de la coagulación
     OT- Other /Otro                       Non Permanent/no es per.         U- Unemployment /Desempleo (Más de 6 meses)                          D- Disability/ Discapacidad                                        Blood Transfusion, Blood
                                           Unknown/ Desconocido             U- Unemployed /Desempleado                                           C- Child Support /Manutención infantil                             Components or Tissue/
                                                                            SS- Social Security /Seguro social                                   F- Farmer /Agricultor                                              Transfusiones de sangre,
                                                                            HR- Home Relief /Casa de socorro                                     MF- Migrant Farmworker                                             productos de sangre o trasplantes
             HEALTH INSURANCE/Seguro de salud                               A- AFDC/ Ayuda a familias con hijos dependientes                     SF-Seasonal Farmworker                                             de tejidos
     NI- No Health Insurance /Sin seguro médico                             SI- Supplemental Sec. Income (SSI/SSD)                               MF=Trabajador agrícola Migrante/ SF= de temporada)                 Hetero Sex/sexo hetero
     D- Disabled /Discapacitado                                             T- TANF/ Asistencia temporal para familias necesitadas               P- Private Disability /Discapacidad privada                        IDU/ drogas inyectadas
     V- Veteran /Veterano                                                   P- Pensions/Retired - Pensión de jubilación                          L- LIHEAP/ Progama de asist. energética                            Men w/Men & IDU hombre con hombre
     M- Medicaid                                                            N- No Income /Sin ingresos                                           W- WIC/Servicios para mujeres, bebés y niños                       Perinatal Transmission
     D- Direct purchase /Compra directa                                     U- Unknown/not reported - Deconocido/ no informado                   S -Section 8 /Sección 8                                            /Transmisión perinatal
     E- Employment based /Por empleador                                     G- General Assistance /Asistencia general                            O- Other /Otro
     S- State children's health insurance program/                                                                      FAMILY SIZE              MILTARY STATUS/ Estado militar                                                  REDUCED
         Programa estatal de seguro médico para niños                     DISCONNECTED YOUTH                           Tamaño del hogar                                                                                           LUNCH
                                                                          Juventud desconectada                                                       Veteran/ Veterano                                                     Almuerzo reducido
         Private Insurance /Seguro privada                             Y-Youth ages 14-24 who are                                                     Active Miltary/ Servicio activo
         Public Insurance /Seguro público                              neither working or in school                                                   Unknown/not reported-Deconocido/ no informado                             FREE LUNCH
         Medicare                                                      Jóvenes de 14 a 24 años que no trabajan
                                                                                                                                                                                                                                almuerzo gratis
         ADAP /Assistencia de medicamentos para el sida                ni están en la escuela
         Unknown /Desconocido

HOUSEHOLD INFORMATION/ Información del grupo familiar

                                                                 D.O.B.          AGE                                                                                                                                  AGE            DIS. (Y/N)
                     NAME / Nombre                                                                                                 NAME / Nombre                                 D.O.B.                 Fec. nac.
                                                                Fec. nac.        Edad                                                                                                                                 Edad          Discapacitado?

WORKER                                                                                                       CLIENT
SIGNATURE: X                                                                                                 SIGNATURE: X
Firma de empleado                                                                                            Firma de cliente
EOC OF SUFFOLK EMERGENCY ASSISTANCE PROGRAM
            To Expedite the Presentation Process, Please Attach:
                                   (Check off each attachment that is attached.)
Complete Presentation Forms Include:

     Statement of Need

     CSBG Intake Form

    Income Attestation and/or Zero Income Attestation

Minimum Required Attachments:

    Last Pay Stubs

    If applying for rental assistance, copy of legal lease – ALL PAGES

    If applying for rental arrears, a letter from a landlord listing the amount in arrears. Must be an
     official bill or notarized letter

    If applying for assistance with other bills – bills must be from current billing cycle, with verified
     balances – ALL PAGES

    W-9 Form needs to get completed by landlord

    Copy of utility bill and/or any other bill that you are requesting payment for

Note: This supporting documentation is required. If a piece of documentation is
unavailable, use every means possible to verify that the client's claim is true
and accurate

.

EOC Authorized Signature: _____________________________________________ Date: ______________

Please send completed application to:

Economic Opportunity Council of Suffolk, Inc.
31 West Main Street, Suite 300
Patchogue, NY 11772

Email: eocassistance@eoc-suffolk.com
Fax: 631-842-5935
                                                                                                             1|Page
CONTACT INFORMATION
         eocassistance@eoc-suffolk.com (631)-842-6100 / Fax: (631)-842-5935

            Economic Opportunity Council of Suffolk, Inc. (EOC’s)
                      Emergency Assistance Program
                           Statement of Need

1. Describe financial hardship/need: Describe the cause of your temporary financial
   hardship/ current situation and what type and amount of assistance you are requesting
   through EOC’s Emergency Assistance Program.

2. Indicate what resources you have accessed: Describe what you have done and or
   resources you have accessed to address your needs prior to requesting assistance through
   EOC’s Emergency Assistance Program.

3. Long Term Recovery Plan – Briefly describe your long-term recovery plan that
   will enable you to gain stability and maintain your needs once assistance is
   provided.

                                                                                  2|Page
DOS DCS Income Attestation Form

                                                                                                      Date: /           /

                                                                                                          Check one:
                                                                                                            Annually
                                                                                                            Bi-weekly
                                                                                                            Weekly
I,_____________________ , attest that my income is $_____________

   By checking this box, I certify that I have experienced a recent loss of income or
job due to the [NYS State of Emergency related to] Covid-19 Outbreak.

I understand that each time I visit the EOC of Suffolk Community Action, Inc., I will
be asked if my income status has changed.

I understand that I may be asked to provide income documentation (to include pay
stubs, benefit letters, tax returns, etc.) at a future date.

                                                         Signed: _____________________________
                                                                                   Date: / /

                                               Staff Witness: _____________________________
                                                                                Date: / /

______ Staff Initials to confirm that information on Child Support Services and Referrals, if applicable, was shared
with this individual.

Contact Information for follow-up:
Name:__________________________
Phone:_(____)_______________
E-mail:___________________________
Household size (circle one): 1 2 3 4 5 6 7 8 9+
DOS DCS Zero-Income Attestation Form

                                                                                                      Date: /          /

I,_____________________ , attest that I have no source of income at this time. I
understand that each time I visit the Economic Opportunity Council of Suffolk, Inc.
Community Action, Inc., I will be asked if my income status has changed.

If my income has not changed, I may be asked to sign an updated Zero- Income
Attestation Form at each future visit.

Should my income status change, I also understand that I am expected to provide
income documentation (to include pay stubs, benefit letters, tax returns, etc.) at
the time of my next visit.

                                                         Signed: _____________________________
                                                                                   Date: / /

                                               Staff Witness: _____________________________
                                                                                Date: / /

______ Staff Initials to confirm that information on Child Support Services and Referrals, if applicable, was shared
with this individual.

Contact Information for follow-up:

Name:__________________________
Phone:_(____)_______________
E-mail:___________________________
Household size (circle one): 1 2 3 4 5 6 7 8 9+
You can also read