COMMUNITY ACTION COMMITTEE OF VICTORIA, TEXAS

UNIFIED INTAKE APPLICATION FOR SERVICES

(361) 578-2989 | 4007 Halsey St. Victoria, TX 77901 | [email protected]

2024 Application Checklist

CERTIFICATION OF COMPLETENESS

If your application is submitted without ALL the required documents listed below,
as they apply to your household, it will be determined as INCOMPLETE and
will not be processed for assistance. Incomplete applications will not be saved.
You will have to re-apply during the next Application Acceptance Period (1-7th of each month.)

Please do not contact us to check the status of your application for 3 weeks from the application date.

ITEMS NEEDED FOR A COMPLETE APPLICATION:

Please check each box – certifying that you are providing each item listed as they apply to anyone in your household.
■ This Checklist. Signed and dated by client.

■ Release & Authorization Form. Signed and dated by client.

■ Filled Out Application for Services.

All INCOME for all household members for the past 30 days: (select all that apply)
✓ Paystubs, & all pages of Benefit Award Letter(s):
SS, SSDI, SSI, SNAP, TANF, Unemployment,
Child Support, VA Benefits, Disability, Retirement, Pension,
Royalties, etc. if NO Income for past 30 days – Declaration of Income Statement Form

■ Current UTILIITES BILLS/ 12 Month History – ■ Electric/ Gas/ Propane/ Water

■ Identification:
o Passport. If Passport is provided, no additional identification is required for that household member.
Otherwise:
o Texas Driver’s License or Texas State Identification Card(s) for all household members 18+
✓
o & Social Security Card(s) for all household members
✓
o & Birth Certificate(s) for all household members

SAVE – HSV Form: Systematic Alien Verification for Entitlements - Household Status Verification Form

I, the undersigned, understand that, if applicable, All items listed above are required with my application for
it to be reviewed for eligibility determination. I understand that my application will not be saved and that
I will not be able to submit missing documents at a later point if I do not include them with my original
application. I Certify that I am submitting all items requested along with my application.

_________________________________________ ___________________________
Client’s Signature (If Digital: Full Name + Last 4 SSN) Date

1|Pa ge
QS 3/13/2024
 COMMUNITY ACTION COMMITTEE OF VICTORIA, TEXAS
UNIFIED INTAKE APPLICATION FOR SERVICES
(361) 578-2989 | 4007 Halsey St. Victoria, TX 77901 | [email protected]

RELEASE & AUTHORIZATION FORM

UNIFIED APPLICATION FOR SERVICES
UTILITIES ASSISTANCE, WEATHERIZATION, COMMUNITY SERVICES

I, ________________________________________, am hereby applying for emergency assistance with

(Print Full Name)
Community Action Committee of Victoria, Texas. Hereby referred to as CACVT. I am applying for any source of
funding through referrals that are available to CACVT, such as United Way, Salvation Army, VCAM, Private donations,
and/or Federal/State funding programs available in the service area.

I understand that any funding sources needed to assist my household may have access to any information contained
in my emergency assistance case file. This also releases CACVT to request information from income sources for
Income Eligibility Determination and Utility Information. CACVT may refer my case, and release information
contained within my case file, for additional services that I may qualify for within the agency as well as to outside
agencies that may be able to provide additional services/ assistance.
Further, I Understand that if I contact the media, CACVT Board Members, TDHCA staff, or elected officials regarding
my case, I grant CACVT permission to discuss the details of my case with those parties to resolve the complaint.

This Release & Authorization form is valid for the entire calendar year in which I am applying
or One Year from Signature Date for Weatherization Services.

 Optional Agent Representation: I hereby appoint the following individual to act as an agent on my behalf. They have my
consent to represent me, ask and answer questions, provide information, and sign in my place. Unless I revoke in writing,
their authority to act on my behalf, they may serve as my representative with CACVT for the same time frame as this
Release & Authorization. Further, I understand that I am still responsible for the information, and its validity, provided to
CACVT and their Funding sources.

(Authorization for representation does not forfeit my responsibility to provide true and honest information on my application for services.)

Name of Agent (Representative): _________________________________

Agent (Representative) Phone Number: _________________________________
Relationship to Applicant: _________________________________
Agent Signature: _________________________________

_________________________________ _________________________
Applicant Signature or Digital Signature Date of Signature
Actual Applicant Signature – NOT AGENT/REPRESENTATIVE
Digital Signature: Full Name + Last four digits of SSN

------------------------------------------------------- Below Line: For Office Use Only --------------------------------------------------------------

_________________________________ _________________________________
Authorized CACVT Staff Signature Date

_________________________________
Case # / Household ID #

Updated March 15, 2024 – Previous Versions Obsolete

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QS 3/13/2024
 COMMUNITY ACTION COMMITTEE OF VICTORIA, TEXAS
UNIFIED INTAKE APPLICATION FOR SERVICES
(361) 578-2989 | 4007 Halsey St. Victoria, TX 77901 | [email protected]

Client ID: Office Use Only

Please select all services you wish to apply for:

Utilities
■ Assistance Weatherization Rental Assistance
Free Internet & Free Tablet Medication Assistance Transportation Vouchers
Home Delivered Meals Senior Service Care Assistance
Hygiene/Household Products Assistance
Home Modifications (Persons w/disabilities) Other: __________________

PART ONE: HEAD OF HOUSEHOLD IDENTIFICATION

Applicant’s Name County Primary Phone Number

Residence Address City State Zip Code Alternate Phone Number

Mailing Address (if different than residence) City State Zip Code Email Address

Social Security Number Date of Birth Age Relationship to Applicant

Gender Race – Highest Level of Military Status Insurance Type Work Status
Select all that apply Education
1 Male 1American Indian/ 10-8 Grade  Active 1 Direct Purchase ■ Employed Full Time
1
2■Female Alaska Native 29-12 Grade (Non-  Veteran ■ Employment Based
2 2 Part Time
3 Other: 2Asian Graduate) ■
 Non-Military 3 Medicaid 3 Short-Term Unemployed
3Highschool 4 Medicare 6 months or less
3Black/African- ■ 5 Military Healthcare 4 Long-Term Unemployed
Ethnicity American Grad/GED Disability Status More than 6 months
6 Children’s Health Ins.
4Native Hawaiian 412+Post-Secondary Program-CHIP 5 Migrant-Seasonal
1 Hispanic  Disabled
/Pacific Islander 52 or 4 year Degree 7 State Health Farm Worker
2  Non-
6Master’s Degree or higher
■
 Not-Disabled
6 Unemployed
Hispanic 5White/Caucasian
■ Insurance for Adults
8 No Insurance Not in Labor Force
6Other: __________ 7 Retired
7Multi-Race 8 Age 16 & younger

Household Type
Number of people in the household: _________
Single Person
■ Non-Related Adults w/children
2 Adults, No Children 2 Parent Household
Single Parent (Female) Mutli-Generational
Single Parent (Male) Other: ______________________

Please select all that apply to ANY household member:

Age 60 or over Military Veteran / Active Duty
Homeless Child(ren) 5 or Younger
Disabled

FOR OFFIE USE ONLY: WEATHERIZATION COMPLETION DATE: ______________________

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QS 3/13/2024
 COMMUNITY ACTION COMMITTEE OF VICTORIA, TEXAS
UNIFIED INTAKE APPLICATION FOR SERVICES
(361) 578-2989 | 4007 Halsey St. Victoria, TX 77901 | [email protected]

PART TWO: ALL HOUSEHOLD MEMBERS INFORMATION

Military Status Disability Status:
Household Member 2:  Active  Veteran  Non-Military  Disabled  Not Disabled
Name Date of Birth Age Social Security Number Relationship to Applicant

Gender Race – Select all that apply Education Level Insurance Type Work Status
1 Male 1 American Indian/ 1 0-8 Grade 1 Direct Purchase 1 Employed Full Time
2 Female or Alaska Native 2 9-12 Grade 2 Employment Based 2 Part Time
3 Other: 2 Asian (Non-Graduate) 3 Medicaid 3 Short-Term Unemployed 6 months or less
3 Black/African- 3 Highschool Grad 4 Medicare 4 Long-Term Unemployed More than 6 months
American or GED 5 Military Healthcare 5 Migrant-Seasonal Farm Worker
Ethnicity 4 Native Hawaiian 4 12+Post-Secondary 6 CHIP-Children’s Health 6 Unemployed Not in Labor Force
1Hispanic or Pacific Islander 5 2 or 4 year Degree Insurance Program 7 Retired
2non-Hispanic 5 White/Caucasian 6 Master’s Degree + 7 State Health 8 Age 16 & younger
6 Other: __________ Insurance for Adults
7 Multi-Race 8 No Insurance

Military Status Disability Status:

Household Member 3:
 Active  Veteran  Non-Military  Disabled  Not Disabled
Name Date of Birth Age Social Security Number Relationship to Applicant

Gender Race – Select all that apply Education Level Insurance Type Work Status
1 Male 1 American Indian/ 1 0-8 Grade 1 Direct Purchase 1 Employed Full Time
2 Female or Alaska Native 2 9-12 Grade 2 Employment Based 2 Part Time
3 Other: 2 Asian (Non-Graduate) 3 Medicaid 3 Short-Term Unemployed 6 months or less
3 Black/African- 3 Highschool Grad 4 Medicare 4 Long-Term Unemployed More than 6 months
American or GED 5 Military Healthcare 5 Migrant-Seasonal Farm Worker
Ethnicity
4 Native Hawaiian 4 12+Post-Secondary 6 CHIP-Children’s Health 6 Unemployed Not in Labor Force
1Hispanic or Pacific Islander 5 2 or 4 year Degree Insurance Program 7 Retired
2non-Hispanic 5 White/Caucasian 6 Master’s Degree + 7 State Health 8 Age 16 & younger
6 Other: __________ Insurance for Adults
7 Multi-Race 8 No Insurance

Military Status Disability Status:

Household Member 4:  Active  Veteran  Non-Military  Disabled  Not Disabled
Name Date of Birth Age Social Security Number Relationship to Applicant

Gender Race – Select all that apply Education Level Insurance Type Work Status
1 Male 1 American Indian/ 1 0-8 Grade 1 Direct Purchase 1 Employed Full Time
2 Female or Alaska Native 2 9-12 Grade 2 Employment Based 2 Part Time
3 Other: 2 Asian (Non-Graduate) 3 Medicaid 3 Short-Term Unemployed 6 months or less
3 Black/African- 3 Highschool Grad 4 Medicare 4 Long-Term Unemployed More than 6 months
American or GED 5 Military Healthcare 5 Migrant-Seasonal Farm Worker
Ethnicity
4 Native Hawaiian 4 12+Post-Secondary 6 CHIP-Children’s Health 6 Unemployed Not in Labor Force
1Hispanic or Pacific Islander 5 2 or 4 year Degree Insurance Program 7 Retired
2non-Hispanic 5 White/Caucasian 6 Master’s Degree + 7 State Health 8 Age 16 & younger
6 Other: __________ Insurance for Adults
7 Multi-Race 8 No Insurance

Military Status Disability Status:

Household Member 5:  Active  Veteran  Non-Military  Disabled  Not Disabled
Name Date of Birth Age Social Security Number Relationship to Applicant

Gender Race – Select all that apply Education Level Insurance Type Work Status
1 Male 1 American Indian/ 1 0-8 Grade 1 Direct Purchase 1 Employed Full Time
2 Female or Alaska Native 2 9-12 Grade 2 Employment Based 2 Part Time
3 Other: 2 Asian (Non-Graduate) 3 Medicaid 3 Short-Term Unemployed 6 months or less
3 Black/African- 3 Highschool Grad 4 Medicare 4 Long-Term Unemployed More than 6 months
American or GED 5 Military Healthcare 5 Migrant-Seasonal Farm Worker
Ethnicity
4 Native Hawaiian 4 12+Post-Secondary 6 CHIP-Children’s Health 6 Unemployed Not in Labor Force
1Hispanic or Pacific Islander 5 2 or 4 year Degree Insurance Program 7 Retired
2non-Hispanic 5 White/Caucasian 6 Master’s Degree + 7 State Health 8 Age 16 & younger
6 Other: __________ Insurance for Adults
7 Multi-Race 8 No Insurance

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QS 3/13/2024
 COMMUNITY ACTION COMMITTEE OF VICTORIA, TEXAS
UNIFIED INTAKE APPLICATION FOR SERVICES
(361) 578-2989 | 4007 Halsey St. Victoria, TX 77901 | [email protected]

PART THREE: INCOME / CASH BENEFITS Select any of the following that anyone in the household receives:
Alimony Retirement from Social Security VA Non-Service-Connected Disability Pension
Child Support Social Security Disability Income (SSDI) VA Service-Connected Disability Compensation
EITC Supplemental Security Income (SSI) Workers Compensation
Pension TANF No Income
Private Disability Insurance Unemployment Insurance Other: ________________________________
■
PART FOUR: NON-CASH BENEFITS Select any of the following that anyone in the household receives:
Affordable Care Act Subsidy HUD VASH Public Housing
Childcare Voucher LIHEAP SNAP
Housing Choice Voucher Permanent Supportive Housing WIC
Other: ________________________________

PART FIVE: HOUSING INFORMATION

Housing Type
Private Home
■ Apartment Duplex
Age of Home:
Single Wide Mobile Home Rented Room Homeless
Double Wide Mobile Home Other: ________________________ Rent/Mortgage Amount: $
Housing Status – Please check all that Apply
Receiving Rent Assistance HUD or Public Housing
Own/Buying Renting
■
Double Wide Mobile Home Other: ______________________
If renting: Contact Information for your landlord
Name Address, City, State, Zip Code County Phone Number

PART SIX: UTILITIES SERVICE INFORMATION

Who does your family pay for heating or cooling? ■ Utility Company Landlord/Manager Included in Rent
Electric Utility Vendor Name:
Electric Utility Vendor Account #: Heat Cool
Gas/Propane Utility Vendor Name:
Gas/Propane Utility Vendor Account #: Heat Cool
Water Company Vendor Name:
Water Company Vendor Account #:
Type of Air Conditioning Used: ■Central Unit Evaporator Cooler Window Unit(s) Number of Units_________ None
Type of Heater Used: Central Unit Fireplace Stove
Wall Furnace Wood Burning Stove Electric Space Heater
Gass Heater None Other: ________________________
PART SEVEN: CERTIFICATION

1. The information contained in the application is true and correct to the best of my knowledge.

2. My household income has been annualized, at the time of application, according to pre-established agency procedure.

3. I understand that I may request a hearing to appeal any denial of eligibility, amount of assistance received, or a delay of assistance.

4. I authorize the Texas Department of Housing and Community Affairs and its contracted agencies to solicit/verify information
on my utility and/or fuel bills, both past and future, to the extent that the information is used only to provide data.

5. I AM AWARE THAT I AM SUBJECT TO PROSECUTION FOR PROVIDING FALSE OR FRAUDULENT INFORMATION.

Applicant Signature: _____________________________________________________________ Date: ________________

5|Pa ge
QS 3/13/2024
 COMMUNITY ACTION COMMITTEE OF VICTORIA, TEXAS
UNIFIED INTAKE APPLICATION FOR SERVICES
(361) 578-2989 | 4007 Halsey St. Victoria, TX 77901 | [email protected]

PART EIGHT: CUSTOMER NEEDS ASSESSMENT

Has Your Home Ever Been Weatherized?

No Yes If Yes, When? Year __________ Month______________

Do You or Any Household Member Need Help or Information Regarding ANY of the Following Items?
FOOD: Housing:
Emergency Food Food Stamps (SNAP) Low Income Housing Rental Assistance
Meals On Wheels Home Delivered Meals Temporary Shelter Weatherization of Home
WIC Other: ____________________ Other: ____________________

EMPLOYMENT TRAINING:
Job Search Assistance GED Preparation Remedial Education(reading, writing, math)
Employment Program for Persons w/ Disabilities or Seniors 55+ ESL (English Second Language) Career Exploration
Job Interview Skills College Entrance Exam prep Vocational/ Tech Training
New Resume or Update Training Programs for Persons w/disabilities or Seniors 55+
Other: ____________________ Other: ____________________

SCHOOL MILITARY/ VETERAN SERVICES

School Clothes School Supplies Employment Job Training
Immunizations/Boosters for school Medical Home Delivered Meals
School Related Physicals Counseling
Other: ____________________ Other: ____________________

HEALTH
Medications Assistance Program Adult Elderly Disabled
Immunizations Pregnancy Services Family Planning
Transportation to Medical Appointments CHIP – Children’s Health Insurance Prog. Blind
Deaf Respite Care Rehab Services
Mental Health Services Elder Care Drug/Alcohol/Substance Abuse info or Services
Affordable Health Insurance Options Other: ____________________

INDIVIDUAL/FAMILY
Domestic Violence
■ Child Abuse/Neglect Elderly Abuse/Neglect
Child/Family Care Youth/Family Support Group/Service  Clothing
Transportation to/from programs Furniture TANF
Financial Counseling Services Other: ____________________

LEGAL SERVICES UTILITIES SERVICES

Child Support Criminal Electric
■ Water
Civil Reconnect Fees
■ Gas/Propane Bills
Administrative: Medicaid, SSI, TANF, Food Stamps, Public Housing, Unemployment, etc. Repairs to Heating & Cooling Appliances
Other: ____________________ Other: ____________________

HOME MODIFICATIONS FOR PERSONS WITH DISABILITIES

Wheelchair Ramp for Access to Your Home Thresholds/Flooring Preventing Wheelchair Access
 Wider Interior/Exterior Doorways Handicap Bathroom Modifications (Toilet, Rails, Shower, etc.)
Life-Threatening Hazards & Unsafe Conditions Other: ____________________

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QS 3/13/2024
 COMMUNITY ACTION COMMITTEE OF VICTORIA, TEXAS
UNIFIED INTAKE APPLICATION FOR SERVICES
(361) 578-2989 | 4007 Halsey St. Victoria, TX 77901 | [email protected]
CLIENT HOME SURVEY
HOME INFORMATION SURVEY: PLEASE ANSWER ALL QUESTIONS BELOW
Name: Address: Phone Number:

Do you rent OR own? Rent

■ Own
Mobile Home (Trailer) Brick House Apartment
Frame (Wood) House
■ Other:_________________________________________________________
Is your Roof Leaking? Yes No
■
If your roof does leak, how many rooms? _________
Are there any holes in your floors? Yes No
■
Does your home have a good foundation? Yes
■ No
How many windows does your home have? _________ Window Material: Wood Aluminum Vinyl
Do you think your windows need to be replaced?Yes No
■
How many exterior doors does your home have? _________
Do you think your Doors need to be replaced? Yes No
■
What material are your walls made of? Sheetrock Paneling
■ Other: __________________
Are there large holes in your walls? Yes, how many? _______ No
■
Are there large holes or cracks in your ceilings? Yes, how many? _______ No
■
Type of Air Conditioning Used: Central Unit
■ Evaporator Cooler Window Unit(s) Number of Units_________ None
Type of Heater Used: Central Unit
■ Fireplace Stove
Wall Furnace Wood Burning Stove Electric/Space Heater: How many? _________
Gass Heater None Other: ________________________

In Your Opinion, What Do You Think Your Home Needs Most?

Please Draw a map showing us where your house is located and a description of your house.

_________________________________ _________________________________
Client’s Signature (If Digital: Full Name + Last 4 SSN) Date

_________________________________ _________________________________
Case # Case Manager Signature

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QS 3/13/2024
 DECLARATION OF INCOME STATEMENT (DIS)
(DECLARACION DE INGRESOS)

Applicant First Name Applicant Last Name Suffix

(Nombre del Solicitante) (Apellido) (Sufijo)
Address City Zip Code
(Dirección) (Ciudad) (Código Postal)

State the gross income for household members, 18 years and older, who have no documentation of the
income received in the 30 day period prior to the date of application for assistance:
(Declarar el ingreso recibido por los miembros de su hogar, que tienen 18 años de edad ó mas, y que no tienen
documentación de ingresos por los 30 dias antes del aplicar para asistencia)

Name Gross Income Received $

(Nombre) (Ingreso Bruto Recibido)
Name Gross Income Received $
(Nombre) (Ingreso Bruto Recibido)
Name Gross Income Received $
(Nombre) (Ingreso Bruto Recibido)
Name Gross Income Received $
(Nombre) (Ingreso Bruto Recibido)

My household has no documented proof of income due to the following situation

(Mi hogar no tiene prueba para documentar los ingresos por medio de tal razones):

I certify that the above information is true and correct to the best of my knowledge and belief.
(Yo certifico que la información proveida de los ingresos es verdadera y correcta según mi saber y creencia.)

I understand that the information will be verified to the extent possible; and that I may be subject to
prosecution for providing false or fraudulent information.
(Comprendo que la información será verificada hasta donde sea posible y que puedo ser enjuiciado por haber
proveido información falsa ó fraudulenta.)

Applicant Signature (Firma del Solicitante) Date (Fecha)

Revised April 2023

|Pa g e
TEXAS DEPARTMENT OF HOUSING AND COMMUNITY AFFAIRS
Household Status Verification Form

Systematic Alien Verification for Entitlements (SAVE) System and US Citizenship/US National
Applicant Certification Form for CEAP, DOE-WAP, LIHEAP-WAP Subrecipients, and SHTF, ESG, HHSP, EH (Political Subdivision only)

The program for which you are applying requires verification that you are a U.S. citizen, a non-citizen national, or a legal resident of the United States.
Documentation of your status is required. This agency uses the Systematic Alien Verification for Entitlements (SAVE) System to verify the status of non-citizens.

U.S. Citizen
Qualified Documentation Provided for:
(Born or Naturalized)
Household Member Name Alien
Of U.S. National
(Yes/No) Citizenship/ Qualified Alien Identification
(Yes/No)

To add additional household members, use another copy of this form.

I AM AWARE THAT I AM SUBJECT TO PROSECUTINO FOR PROVIDING FALSE OR FRAUDULANT INFORMATION.

Applicant’s Signature Date

Signature of agency staff certifying they verified the above documents Print Staff Name Date

HSV Form: Updated 12/2019 Previous Versions Obsolete |Pa g e