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Houston Harris County Winter Storm Relief Program Assessment
Application for Services
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* Indicates required question
Does any of the following apply to you or members of your household
*
Legal permanent residents and naturalized immigrants
Limited English proficient poplulation
People with intellectual and Development Disabilities
People with physical disabilities
People with special medical needs
Medically uninsured
Individuals experiencing homelessness
Human trafficking survivors
Domestic violence survivors/victims
Youth in foster care/aging-out
Previously incarcerated/involved with criminal justice system
LGBTQIA+Gender Non-Conforming (GNC)
Military Veteran
Working families who are ALICE (Asset Limited, Income Constrained, Employed)
Mixed-immigration-status Households
People without flood insurance or renter's insurance
Other:
Required
Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Current Address
*
Your answer
Contact Information
*
Your answer
Email Address
*
Your answer
Language Preference
*
Your answer
U.S. Military Veteran
*
Choose
Yes
No
Client Refuse
Relationship to Home Owner
*
Choose
Self (Homeowner)
Homeowners immediate family member (parent, spouse, child, sibling, or other relative
Other: Renter or Tenant
Race
*
American Indian or Alaska Native
Black or African American
Native Hawaiian or Pacific Islander
White
Don't Know
Applicant Refused
Ethnicity
*
Non-Hispanic/Non-Latino
Hispanic/Latino
Don't Know
Applicant Refused
Gender
*
Female
Male
Prefer not to say
Other:
Did the applicant live in the home prior to Houston Harris County Winter Storm 2021?
*
Yes
No
Applicant Doesn't Know
Below List all persons who will be living in your home, listing, yourself first. You must also list the relationship of the person to you (for example, husband/wife/boyfriend/girlfriend/son/daughter/foster child/live-in aid/grandchild, etc.
Your answer
1. Relationship to HOH
*
Your answer
Last, first, middle initial
*
Your answer
DOB
*
MM
/
DD
/
YYYY
Age
*
Your answer
Race
*
American Indian or Alaska Native
Black or African American
Native Hawaiian or Pacific Islander
White
Don't Know
Applicant Refused
Living Status
*
Choose
Homeowner
Renter
N/A
Disabled?
*
Yes
No
2. Relationship to HOH
*
Your answer
Last, first, middle initial
*
Your answer
DOB
*
MM
/
DD
/
YYYY
Age
*
Your answer
Race
*
American Indian or Alaska Native
Black or African American
Native Hawaiian or Pacific Islander
White
Don't Know
Applicant Refused
Living Status
*
Choose
Homeowner
Renter
N/A
Disabled?
*
Yes
No
3. Relationship to HOH
*
Your answer
Last, first, middle initial
*
Your answer
DOB
*
MM
/
DD
/
YYYY
Age
*
Your answer
Race
*
American Indian or Alaska Native
Black or African American
Native Hawaiian or Pacific Islander
White
Don't Know
Applicant Refused
Living Status
*
Choose
Homeowner
Renter
N/A
Disabled?
*
Yes
No
4. Relationship to HOH
Your answer
Last, first, middle initial
Your answer
DOB
MM
/
DD
/
YYYY
Age
Your answer
Race
American Indian or Alaska Native
Black or African American
Native Hawaiian or Pacific Islander
White
Don't Know
Applicant Refused
Clear selection
Living Status
Choose
Homeowner
Renter
N/A
Disabled?
Yes
No
Clear selection
5. Relationship to HOH
Your answer
Last, first, middle initial
Your answer
DOB
MM
/
DD
/
YYYY
Age
Your answer
Race
American Indian or Alaska Native
Black or African American
Native Hawaiian or Pacific Islander
White
Don't Know
Applicant Refused
Clear selection
Living Status
Choose
Homeowner
Renter
N/A
Disabled?
Yes
No
Clear selection
Residence
Own
Lease
Rent to Own
Mortgage
Other:
Source of Income
*
Employment
Social Security Benefits
Retirement Pension
Alimony
Child Support
Disability
Unemployment
If disability is your source of income please indicate your disability(s):
Other:
Required
Below please list all individuals in the household with an income. Along with the source the amount and the frequency.
Your answer
1.Individual
*
Your answer
Source of Income
*
Employment
Social Security Benefits
Retirement Pension
Alimony
Child Support
Disability
Unemployment
If disability is your source of income please indicate your disability(s):
Other:
Required
Amount
*
Your answer
Frequency
*
Once a Month
Semi Monthly
Bi-Weekly
Weekly
Daily
Required
2. Individual
Your answer
Source of Income
Employment
Social Security Benefits
Retirement Pension
Alimony
Child Support
Disability
Unemployment
If disability is your source of income please indicate your disability(s):
Other:
Amount
Your answer
Frequency
Once a Month
Semi Monthly
Bi-Weekly
Weekly
Daily
3. Individual
Your answer
Source of Income
Employment
Social Security Benefits
Retirement Pension
Alimony
Child Support
Disability
Unemployment
If disability is your source of income please indicate your disability(s):
Other:
Amount
Your answer
Frequency
Once a Month
Semi Monthly
Bi-Weekly
Weekly
Daily
4. Individual
Your answer
Source of Income
Employment
Social Security Benefits
Retirement Pension
Alimony
Child Support
Disability
Unemployment
If disability is your source of income please indicate your disability(s):
Other:
Amount
Your answer
Frequency
Once a Month
Semi Monthly
Bi-Weekly
Weekly
Daily
Electronically sign your name below. This is to certify the income status for the above name individual. Income includes but is not limited:
*
Your answer
Source/ Amount/Frequency
*
Your answer
Source/ Amount/Frequency
Your answer
Source/ Amount/Frequency
Your answer
YWCA Participant's Name (Electronic Signature Required)
*
Signature: _______________________________________________________________________
I certify, under penalty of perjury, the answer stated above are true to my knowledge and if found any false information will forfeit me from receiving any services.
Required
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