Support Service Program for Survivors of Domestic Violence

Family Permanency Project

Support Service Program for Survivors of Domestic Violence

Client Application

The Family Permanency Project (FPP) is a housing program with supportive services intended to achieve economic and personal self-sufficiency.

The YWCA Pierce County housing program provides support services and rental subsidy to families that have recently fled a domestic violence situation as they transition from homelessness to stable housing and self-sufficiency. The YWCA housing program provides a wide range of flexible and optional services that reflect the differences and individual needs of survivors and their dependent children that allow them to choose the course of action that is best for them. The housing program offers individualized services such as safety planning, advocacy services, case management, and referrals to other services for counseling, employment, child care, legal, support groups, etc.

Qualified applicants will be eligible for approval from the Pierce County Housing Authority Section 8 program. Participant costs will increase proportionally to increase in income. Participants agree to establish an Individualized Service Plan and Safety Plan with their case manager and actively work toward their goals while in the program. Participants agree to comply with the regulations of the Housing Authority and their rental agreement.

Qualified applicants will meet the following criteria:

·  Homeless as defined by one or more of the below

o  1. Literally Homeless

o  2. Imminent Risk of Homelessness

o  3. Homeless under other Federal Status

o  4. Fleeing or Attempting to flee DV

·  Able and willing to work toward achieving identified goals

·  Meet and maintain requirements and expectations of the Pierce County Housing Authority

·  Be parenting dependent children in the home

·  Be a survivor of recent domestic violence who has already accessed emergency services (such as shelter, legal assistance, advocacy)

Please fax, mail or email completed Agency Referral and Client Application to:

YWCA Pierce County

ATTN: Rolinda Alonzo

405 Broadway

Tacoma, WA 98402

Fax: 253.597.6683

We are unable to process or retain incomplete referrals and applications, so please ensure all documentation is attached. Please call (253) 272-4181 x 229 if you have any questions.

Please provide the following information truthfully and to the best of your ability to assist us in determining if our housing program is appropriate for you and your family.

Name: ______Date: ______

(Last) (First) (Middle Initial)

Age: ______Date of Birth: ______Phone: ______

Child’s name: M/F Age/Grade Date of Birth

______

______

______

______

______

______

______

______

Do you anticipate other children living with you within the next 12 months? Please explain:

______

What is the reason for your current homelessness?

______

Pierce County Housing Authority Eligibility Guidelines

Ability to pass the Housing Authority criminal and arrest records background search ___yes ___no?

Have you ever rented from a property owned by any Housing Authority ___yes ___no?

Do you owe any Housing Authority money ___yes ___no?

Have you ever been arrested ___yes ___no? If yes, please list all arrests and how many times arrested for the same incident: ______

______

Do you have any outstanding warrants ___yes ___no? Where and what for? ______

______

Do you have any felonies ___yes ___no? If yes, please list the felonies and how long ago: ______

______

Do you have a misdemeanor related to drugs or alcohol within the last year ___yes ___no?

If yes, are you currently receiving or completed classes or a program related to the misdemeanor and what agency provided the service: ______

Are you an undocumented immigrant ___yes ___no? If so are you able to provide documentation that you are in the process of obtaining qualified alien status ___yes ___no?

Are you willing to sign a Release of Information for the Housing Authority to verify your eligibility with the Immigration Customs Enforcement (ICE) ___yes ___no?

What are the obstacles you face in finding and maintaining stable housing? (GED, education, never lived on own, employment, CPS, evictions, ability to consistently pay rent, utilities, bills etc.)

______

______

Do you have some means of transportation? Yes / No

If yes, what is it? ______

Are you currently enrolled in school or other training program? ______

If yes, where: ______

What field of study: ______anticipated completion date: ______

If chosen for this program, how would your participation help you meet your goals for self-sufficiency? How would you take advantage of the services offered to successfully gain independent living? (Independent living is defined as: being able to successfully navigate day to day living on your own without another adult moving in or living with you. It is prohibited by the YWCA and the Housing Authority to move another person in to your unit without following the appropriate process to add them to the lease).

______

______

______

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PLEASE NOTE: Expectation of Safety and Lease Compliance

As an applicant you are qualifying for FPP as a DV survivor. You may not at any time have your abuser or any person not authorized on the lease cohabitate with you in this housing.

Abuser(s) Name: ______Age ______

______Age______

______Age______

Physical description(s):

______

______

______

______

When did the last incident of abuse occur? ______

Are there any areas in which you feel unsafe to live or travel? ______

Is/Are the abuser(s) the parent of any of your children, or have visitation? What arrangements have you made for visitation exchange? What is your safety plan for this exchange?

______

______

Income Information

Amount Application Date

Supplemental Security

Income (SSI) ______

Social Security

Disability Income (SSDI) ______

Social Security (65+) ______

Spousal Maintenance ______

Temporary Aid to

Needy Families (TANF) ______How many months received ______

Child Support ______

Veteran’s Benefits ______

Employment Income ______f/t or p/t ______employee benefits______

Unemployment Benefits ______benefit ends on ______

Food assistance ______

Other

(Please Specify) ______

Bank Account Balance(s) ______, ______, ______(list all)

No Financial Resources please explain:______

______

______

______

Please attach copies of the following documentation with this application if applicable:

o  Birth Certificates (certified copy) for all family members

o  Income (i.e. pay check stubs, Award letter for TANF, SSI, Child Support)

o  Food Assistance (Award Letter for Food Assistance)

o  Washington ID for all family members 18 YRS. OR OLDER

o  Social Security cards for all family members

o  Immigration Status

o  Bank Accounts and related bank statements

o  Pregnancy

All applicable documentation is REQUIRED for consideration to the YWCA Housing program. We are unable to process or retain incomplete applications. So please ensure all documentation is attached.

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