Check data quality option: ☐Full Name ☐Partial, street or code name ☐Client doesn’t know ☐Client refused ☐Data not collected
Maiden Name (if applicable) / Alias or any other names used
Social Security Number(SSN)
Check data quality option: ☐Full SSN ☐Approx. or partial SSN ☐Client doesn’t know ☐Client refused ☐Data not collected
U.S. Military Veteran / ☐Yes ☐No ☐Client doesn’t Know ☐Client Refused ☐Data not collected
Date Client Entered Project / Project Name
Household Relationship Information (select one) / ☐Couple with No Children
☐Couple (Parent & Friend) with Child(ren)
☐Foster Parent
☐Grandparent(s) &Child(ren)
☐Non-Custodial Caregivers / ☐Single Female Parent
☐Single Male Parent
☐Single Person
☐Two Parent Family
☐Other
Date of Birth (DOB) / ☐Full DOB ☐Approx. or partial DOB☐Client doesn’t know ☐Client refused
Gender
(select one) / ☐Female
☐Male
☐Transgender male to female
☐Transgender female to male / ☐Client doesn’t know
☐Client refused
☐Data not collected
☐Other: ______
Race
(select up to 2) / ☐American Indian or Alaska Native
☐Asian
☐Black or African American
☐Native Hawaiian/Pacific Islander / ☐White
☐Client doesn’t know
☐Client refused
☐Data not collected
Ethnicity / ☐ Non-Hispanic/Non-Latino ☐ Hispanic/Latino ☐Client doesn’t know ☐Client refused ☐Data not collected
Have a disability of long duration? / ☐Yes ☐No ☐Client doesn’t know ☐Client refused ☐Data not collected
Housing Status / ☐Category 1-Homeless ☐Category 2-At imminent risk of losing housing
☐Category 3-Homeless under other federal statutes
☐Category 4-Fleeing domestic violence / ☐At-risk of homelessness
☐Stably housed
☐Client doesn’t know
☐Client refused
☐Data not collected
Residence Prior to Project Entry / ☐ Emergency shelter, including hotel or motel paid for criteria
☐ Foster care home or foster care group home
☐ Hospital or other residential non-psychiatric medical facility
☐ Hotel or motel paid for without emergency shelter voucher
☐ Jail, prison or juvenile detention facility
☐ Long-term care facility or nursing home
☐ Owned by client, no ongoing housing subsidy
☐ Owned by client, with ongoing housing subsidy
☐ Permanent housing for formerly homeless persons
☐ Place not meant for habitation
☐ Psychiatric hospital or other psychiatric facility
☐ Rental by client, no ongoing housing subsidy
☐ Rental by client, with VASH subsidy
☐ Rental by client, with GPD TIP subsidy / ☐ Rental by client, with other ongoing housing subsidy
☐ Residential project or halfway house with no homeless criteria
☐ Safe Haven
☐ Staying or living in a family member's room, apartment or house
☐ Staying or living in a friend's room, apartment or house
☐ Substance abuse treatment facility or detox center
☐ Transitional housing for homeless persons (including homeless youth)
☐ Client doesn’t know
☐ Client refused
☐ Data not collected
☐Other(specify):______
Length of Stay in Previous Place / ☐ One day or less
☐ Two days to one week
☐ More than one week, but less than one month
☐ One to three months
☐ More than three months, but less than 1 year / ☐ One year or longer
☐ Client doesn’t know
☐ Client refused
Zip Code of Last Permanent Address / Client Location / ☐NE-500 BOS (Anywhere in Nebraska outside of Lincoln/Omaha)
☐NE-501 MAACH(Omaha)
☐NE-502 Lincoln
Relationship to Head of Household / ☐Self (head of household)
☐ Head of Household’s Child
☐ Head of Household’s spouse or partner
☐Head of Household’s other relation member / ☐ Other: Non-relation member
☐ Client doesn’t know
☐ Client refused
☐ Data not collected
Client entering from the streets, ES or SH / ☐Yes ☐No ☐Client doesn’t know ☐Client refused ☐Data not collected
If yes to entering from the streets, ES or SH Approximate date started
Regardless of where they stayed last night-Number of Times the client has been on the streets, in ES or SH in the past three years including today / ☐Never in the 3 years ☐One time☐ Two times ☐Three times ☐Four or more times
☐Client doesn’t know ☐Client refused ☐Data not collected
Total Number of Months Homeless on the street, in ES or SH in the Past Three Years(partial month =1) / ☐One Month(first time) ☐2 ☐3 ☐4 ☐5 ☐6 ☐7 ☐8 ☐9 ☐10 ☐11 ☐12
☐More than 12 ☐Client doesn’t know ☐Client refused ☐Data not collected
Length of Time Homeless Status Documented? / ☐Yes ☐No
As a child, were you ever in Foster Care or are you now? / ☐Yes ☐No
Domestic violence victim/survivor? / ☐Yes ☐No ☐Client doesn’t know ☐Client refused ☐Data not collected
If yes for Domestic Violence victim/survivor, when experience occurred / ☐Within the past three months
☐Three to six months ago
☐From six to twelve months ago
☐More than a year ago / ☐Client doesn’t know
☐Client refused
☐ Data not collected
If yes for Domestic Violence Victim/Survivor, are you currently fleeing? / ☐Yes ☐No ☐Client doesn’t know ☐Client refused ☐Data not collected
Highest level of education attained / ☐No schooling completed
☐Nursery school to 4th grade
☐5th or 6th grade
☐7th grade or 8th grade
☐9th grade
☐10th grade
☐11th grade
☐12th grade, no diploma
☐ Some High School
☐High school diploma / ☐GED
☐Post-Secondary School
☐Some College
☐ Some Technical School
☐ Graduate Degree / ☐ Technical School Certification
☐Client refused
☐ Client Doesn’t Know
Income Information
Income from any source? / ☐Yes ☐No ☐Client doesn’t know ☐Client refused ☐Data not collected
Total Monthly CASH income: Write in total $ amount and complete the table below Total Monthly Income: $______
Receives Income Sources / Yes / Monthly Amount $ / No / Not Collected
AABD (Aid to Aged, Blind & Disabled) / ☐ / $ / ☐ / ☐ /
Alimony or Other Spousal Support / ☐ / $ / ☐ / ☐ /
Child Support / ☐ / $ / ☐ / ☐ /
Contributions from other People / ☐ / $ / ☐ / ☐ /
Earned Income (from job) / ☐ / $ / ☐ / ☐ /
General Assistance / ☐ / $ / ☐ / ☐ /
Pension or retirement income from job / ☐ / $ / ☐ / ☐ /
Pension/Retirement / ☐ / $ / ☐ / ☐ /
Private Disability Insurance / ☐ / $ / ☐ / ☐ /
Retirement Income from Social Security / ☐ / $ / ☐ / ☐ /
Self Employment Wages / ☐ / $ / ☐ / ☐ /
SSA / ☐ / $ / ☐ / ☐ /
SSDI / ☐ / $ / ☐ / ☐ /
SSI / ☐ / $ / ☐ / ☐ /
Stipend / ☐ / $ / ☐ / ☐ /
Unemployment Insurance / ☐ / $ / ☐ / ☐ /
VA Non-service connected disability compensation / ☐ / $ / ☐ / ☐ /
VA service-connected disability compensation / ☐ / $ / ☐ / ☐ /
Worker’s Compensation / ☐ / $ / ☐ / ☐ /
Other (specify): / ☐ / $ / ☐ / ☐ /
Non-Cash Benefits Information
Non-cash benefits from any source / ☐Yes ☐No ☐Client doesn’t know ☐Client refused ☐Data not collected
Receives the following Non-cash Benefit Types: / Yes / Monthly Amount $ (if known) / No / Not Collected
Supplemental Nutrition Assistance Program (SNAP)(Food Stamps) / ☐ / $ / ☐ / ☐ /
Special Supplemental Nutrition for Women, infants, children(WIC) / ☐ / N/A / ☐ / ☐ /
TANF Child Care Services / ☐ / $ / ☐ / ☐ /
TANF Transportation services / ☐ / N/A / ☐ / ☐ /
Other TANF funded services / ☐ / N/A / ☐ / ☐ /
Section 8, public housing, or other ongoing rent assistance / ☐ / $ / ☐ / ☐ /
Temporary rental assistance / ☐ / $ / ☐ / ☐ /
Other (specify): / ☐ / $ / ☐ / ☐ /
Health Insurance Information
Covered by Health Insurance / ☐Yes ☐No ☐Client doesn’t know ☐Client refused ☐Data not collected
Type
(Select all that apply) / Covered
Yes / Covered
No
Medicaid / ☐ / ☐ /
Medicare / ☐ / ☐ /
State Children’s Health Insurance Program / ☐ / ☐ /
Veteran’s Administration (VA) Medical Services / ☐ / ☐ /
Employer-Provided Health Insurance / ☐ / ☐ /
Health Insurance obtained through COBRA / ☐ / ☐ /
Private Pay Health Insurance / ☐ / ☐ /
State Health Insurance for Adults / ☐ / ☐ /
Client’s Residence/Last Permanent Address
Street Address
City / State / Zip code
County of Current Residence / County of Legal Residence
Preferred Method of Contact
Home Phone Number / Cell Phone / Work
Please Note: UYSS offers financial assistance only twice in one year to the same candidate.
Referral Source: ______Agency ____Self ____Family ____Friend ____Other
Grant Amount Requested:______
Name of who to make the check payable to: ______
Title (landlord, etc.): ______Phone: ______
Address: ______
Additional Information: ______
Are you affiliated with a church?______Would you like to be?______
Is this request for rent or utility assistance? If YES, you may be a candidate for assistance through the community-wide Basic Needs initiative. If NO, please answer the question below:
To verify gap in services, please explain why the following agencies are unable to provide assistance:
___General Assistance (402-727-2731): (results) ______
___Salvation Army Church (402-721-0930): (results) ______
___Low Income Ministry (402-727-6884): (results) ______
___NENCAP (402-721-0619): (results)______
Please provide AT LEAST ONE of the following items with the UYSS Referral Form:
(Note: Please check which items you are including)
_____Photo ID _____SS Card _____Proof of Citizenship _____Other
If requesting a gas voucher, you must also provide proof of ALL of the following:
_____Driver’s License_____Proof of Insurance _____Registration
What is the hardship that threatens your housing stability?______
______
What do you think would happen to your housing stability if you were not granted funds at this time? ______
______
I am requesting funds from UYSS as a solution to a hardship and agree that the resources will go directly to the solution and not to me. I agree to allow UYSS to track my progress for one year.
Signature:______Date: ______
Printed Name: ______UYSS Representative: ______
For staff use only: _____BN _____UYSS _____GAS ____MOH ____HP CL#______