Checklist for rapid response
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| CHECKLIST FOR RAPID RESPONSE
Income Verification: All documentation must be no later than 30 days old.
Proof of Residency:
If Rental Arrears (Rent Owed) Needed:
If Security Deposit Needed:
Stabilization Application APPLICANT NAME: Current Address: _______ Home Phone: Alternate Phone:
Is a change in the household composition expected? YES NO If yes, what type of change?__________________________________________ When?_______________
Hispanic or Latino Not Hispanic or Latino Race of Household (Check All that apply) – Optional White Black/African American Asian/Pacific Islander American Indian/Alaskan Native Native Hawaiin/Other Other Check All That Apply to You:
CIRCUMSTANCES (ALL questions must be answered) Please describe in detail all of the following:
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________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ MAINTENANCE (ALL questions must be answered) 1. How will you be able to pay your expenses after assistance? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 2. Difficulties you expect in maintaining monthly expenses? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 3. How much are you able to pay toward debt? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ (Circle one) 1. Is any member of your household employed, part time, full-time YES NO or seasonal? 2. Does any member of your household expect to work during the YES NO next twelve months? 3. Does anyone in your household work for someone who pays them in cash? YES NO 5. Does any member of your household receive or expect to YES NO receive child support? 6. Does any member of your household receive or expect to YES NO receive alimony payments? 7. Is any member of your household entitled to child support YES NO payments that he/she is not receiving? 8. Is any member of your household not receiving alimony payments YES NO that he/she is entitled to receive? 9. Does any member of your household receive or expect to YES NO receive unemployment benefits? 10. Does any member of your household receive or expect to YES NO receive welfare payments (TAFDC, SSI or EAEDC)? 11. Does any member of your household receive or expect to YES NO receive Social Security benefits (SSDI or retirement)? 12. Does any member of your household receive or expect to YES NO receive an income from a pension or annuity? 13. Does any member of your household receive regular cash contributions from anyone not living in the household or from any agency? YES NO 14. Does any member of your household receive income from assets, YES NO including interest on checking or saving accounts, interest or dividends from certificates of deposits, stocks, bonds, or income from the rental of property? 15. Does any member of your household receive or expect to receive YES NO an earned income tax credit? 16. Do you own a home or any other real estate? YES NO 17. Have you sold or given away any real property or any other YES NO assets in the past two years? BUDGET Income:
Expenses: For ALL expenses paid. Under the Priority column Please number in numerical order (with 1 being the first bill you pay) how you pay your bills for the month, first (1), second (2), third (3), etc…
Asset Information: List the type and source of any family assets. Provide both the current cash value and the estimated annual income from the asset.
Landlord Verification: List your current landlord. If you are staying in a shelter, with family or friends provide information for the most recent landlord information prior to homelessness. Landlord’s Name:__________________________________________________________________________ Address: ________________________________________________________________________________ Telephone Number:________________________________________________________________________
Do you receive rental assistance? Section 8 MVRP Yes No Do you reside in public housing? Yes No Are there any utilities included in your rent? Yes No List utilities included in rent: ________________________________________________
If yes when? _______________ By how much was the rent raised? $________________ How many bedrooms in your current living situation? _________________ How many members of your family are living with you currently? (Do not include yourself) _______ IF approved for funding from the Rapid Response Program, would you be willing to participate in a follow-up survey? This survey is voluntary and the answer below will not have any effect on decisions made in regards to applicant eligibility for the Rapid Response Program.
Application Certification and Release of Information: I/We certify the information that I have given in this application is true and correct, and I/We understand that any false statement or misrepresentation may result in the rejection of my application. I/We authorize the Somerville Homeless Coalition to make inquires to verify the information that I have provided in this application. I/We authorize the Somerville Homeless Coalition to discuss this application with the Somerville Housing Assistance Committee. I understand that my records cannot be disclosed without my written consent and that I may revoke this consent at any time, although I recognize some actions may have already been taken on my behalf. I also understand that the information so released will be held in the strictest confidence by its recipient. I understand that this release form is valid for one year from the date it is signed. Head of Household Signature Date Co-Head of Household Signature Date Other member of household over age 18 Date Other member of household over age 18 Date 
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