Fss Program Application Form PDF Details

The Family Self-Sufficiency (FSS) Program Application Form serves as a critical initial step for applicants wishing to join the program offered by the Housing Authority of the City of San Luis Obispo. This document collects comprehensive information about the applicant, including legal name, contact information, emergency contacts, marital status, and the details of other household members. It delves into previous education, enquiring about the highest grade completed, current enrollments in classes or training programs, and involvement in work programs. The form also explores the applicant's current income and employment history, detailing sources of income, welfare benefits, employment status, and history, alongside any volunteer work conducted by the applicant. Support service needs are also addressed, asking applicants to identify needs in areas such as childcare, financial management, career counseling, and more, to ensure a tailored approach to the assistance provided. The application concludes with a certification and release of information section, where the applicant must affirm the truthfulness of their statements and authorize the housing authority to verify the information and discuss their application with relevant committees. This thorough application process reflects the program's commitment to understanding the holistic needs of applicants to effectively support their journey towards self-sufficiency.

QuestionAnswer
Form NameFss Program Application Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesLUIS, medi, fss aplication, CompletedYes

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APPLICATION FOR

THE FAMILY SELF-SUFFICIENCY PROGRAM

OF THE HOUSING AUTHORITY OF THE CITY OF SAN LUIS OBISPO

Applicant's Legal Name (Last, First, MI)

 

Home Phone Number / Cell Phone Number

 

 

 

/

Address:

 

 

 

 

 

 

 

Street

City

State

Zip

__________________________________________________________________________________________

E-Mail Address

Mailing Address (if different than above)

Address:

Street

 

 

City

State

 

Zip

∙ Emergency Contact & Telephone No.

 

 

 

 

 

∙

Marital Status: Married

Single

Divorced

Separated

Widowed

∙

Spouse/Co-head Name:

 

 

 

 

 

 

 

Does this person wish to participate in the Family Self-Sufficiency Program? Yes No

∙List all dependents and other adults living in your home: (First & last name)

Name

 

Relationship

 

Date of Birth

 

Age

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I. Previous Education

∙Highest School Grade Completed (Circle one): 1 2 3 4 5 6 7 8 9 10 11 12 GED

College 1 2 3 4 5+ Degree/s:Major/s:

∙ Are you presently enrolled in any classes or training programs?Yes No

Name of School

 

Courses of study

∙Are you currently enrolled in a work program? (CalWORKS, Shoreline/One-Stop, Dept. of Rehabilitation, etc.)

Name of program:

 

 

 

 

Worker's name:

 

 

Date you began:

 

 

 

 

 

 

 

 

 

∙ Have you ever been enrolled in a training program? Yes

No

 

List agency

 

 

 

 

 

Worker's name

 

 

Dates of enrollment: from

 

to

 

 

Completed?Yes

No

Training and certificates received:

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

∙ List agency

 

 

 

 

 

Worker's name

 

 

∙ Dates of enrollment: from

 

to

 

 

Completed?Yes

No

II.Current Income & Employment History

Income

∙What is your family's current income? (please list all sources)

Amount

(Hour, week, month)

 

Source

$

 

 

per

 

 

 

$

 

 

per

 

 

 

$

 

 

per

 

 

 

Other:

 

 

 

 

 

∙Do you receive welfare benefits? (Check those that apply)

CalWORKS (TANF)

Food Stamps

Medi-Cal

(Transitional Medi-Cal)

General Relief

SSI

Employment

∙ Are you currently working?Yes No

 

 

 

 

 

Place of Employment:

 

 

 

 

 

 

 

Name of supervisor

 

City

 

Rate of pay

 

 

Hours per week

 

Dates of employment: from

 

 

 

 

to

 

PRESENT

 

Job title:

 

 

Duties:

 

 

 

 

 

 

∙List previous jobs you have held (most recent first):

A) Place of Employment:

 

 

 

 

 

Name of supervisor

 

City

 

Rate of pay

 

 

Hours per week

 

Dates of employment: from

 

 

 

 

 

 

to

 

 

Job title:

 

 

Duties:

 

 

 

 

 

 

 

Why did you leave?

 

 

 

 

 

 

 

 

 

 

 

B) Place of Employment:

 

 

 

 

 

Name of supervisor

 

City

 

Rate of pay

 

 

Hours per week

 

Dates of employment: from

 

 

 

 

 

 

to

 

 

Job title:

 

 

Duties:

 

 

 

 

 

 

 

Why did you leave?

 

 

 

 

 

 

 

 

 

 

 

C) Place of Employment:

 

 

 

 

 

Name of supervisor

 

City

 

Rate of pay

 

 

Hours per week

 

Dates of employment: from

 

 

 

 

 

 

to

 

 

Job title:

 

 

Duties:

 

 

 

 

 

 

 

Why did you leave?

 

 

 

 

 

 

 

 

 

 

 

∙List any volunteer work you have done

III.Support Service Needs

Childcare:

 

 

 

 

 

 

∙

Do you currently pay childcare expenses?

Yes $

 

 

per week

No

∙

Do you receive a subsidy to help you pay your child care expense? Yes

No

 

What agency/source helps you?

CAPSLO-CCRC

CARE Program/EOPS

 

Financial Aid for school

Dept. of Rehab.

Other

 

∙ List the names of your children for whom you would need childcare services if you went to school or to

 

work:

1.

 

4.

2.

 

5.

3.

 

6.

∙If you were selected to participate in this program, what support services would you need?

Childcare

Money management

Credit repair

Transportation assistance

Career counseling

Personal/family counseling

GED/High School education

Reading skills

Home ownership

Job training

English skills

Other

Higher education

Medical care

 

 

Job placement

Drug/alcohol counseling

 

 

∙What kind of a job would you like to have?

∙

Do you require any accommodations for handicap accessibility? Yes

No

∙

If yes, what accommodations do you need?

 

 

 

Do you need TDD/TDY access to our staff? (For hearing impaired)

Yes

No

∙

Do you owe the Housing Authority of San Luis Obispo any money?

Yes

No

∙

Have you ever applied to the Family Self-Sufficiency Program? Yes

No

If Yes, the approximate date that you applied:

CERTIFICATION AND RELEASE OF INFORMATION:

I hereby certify and affirm under penalties of perjury that the above statements are true and correct. I understand that the Housing Authority of San Luis Obispo will verify the statements herein, and I have no objections to inquiries made.

Warning! Section 1001 of Title 18 of the U.S. Code make sit a criminal offense to make willful false statements or misrepresentations to any Department or Agency of the U.S. as to any matter within its jurisdiction.

I hereby give my permission for the Housing Authority of San Luis Obispo to discuss and review my application with the Program Coordinating Committee and to release information they deem necessary prior to my admittance to the Family Self-Sufficiency Program.

Signature of Applicant:

 

Date

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