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