HERNANDO RESIDENT INFORMATION
Hernando County, FL Resident LAST NAME:
Hernando County, FL Resident FIRST NAME:
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Length of time at current address:
Have you ever served in the military?
Have you previously submitted a United Way of Hernando County CRA application?
Were you a recipient of United Way of Hernando County’s CRA program in 2020?
How many people are in your household (including yourself):
List all ages and genders for each of the individuals above (including yourself):
Please select the race you most identify with:
How were you impacted by COVID-19?
Please select all of the unmet needs you are currently experiencing as a result of COVID-19:
In detail, please explain in your own words how COVID-19 has financially impacted you? Please be specific.
If you were referred by an Apartment Complex, Landlord, Utility Company, Agency, or Individual, who referred you?
Main source(s) of income for household:
If currently employed, how would you identify your work industry?
Previous Employer (if applicable):
Current Employer (if applicable):
Employer contact name:
Employer Phone Number:
Does your employer give you the option to work from home?
How much have you lost in wages/income due to the impact of COVID-19? (Please give a rough estimate)
Do you currently bank with a financial institution?
If not, what are some barriers preventing you from doing so?
Do you believe you fall into the ALICE population, being one crisis away from poverty? (Asset Limited, Income Constrained, Employed)
Type of assistance requested:
Do you currently live in a:
Do you rent or own the property stated above?
Housing Contact Name:
Housing Contact Phone Number:
Monthly rent/mortgage amount:
Have you received an eviction notice?
Is your rent subsidized?
Have you received a shut off notice?
IF OTHER assistance needed:
Qualified Hernando County residents will be contacted with further instructions and appointment scheduling.
In the event you are scheduled an appointment with an United Way representative, please indicate which method you would be available to conference with (please select preferred method):
Have you received or do you anticipate receiving any other local, state, federal, or private financial assistance related to the impacts of COVID-19?
Including but not limited to: Economic Impact Payment (stimulus payment), Pandemic Unemployment Assistance, funding through any other CARES Act program from another local agency, or private insurance.
Please note, by selecting YES, this does not disqualify you from receiving assistance through United Way's CRA.
If Yes, please fill out the following information below:
Source of Funds #1
Source of Funds #2
I acknowledge and agree that the United Way of Hernando County may request additional supporting documents or records from me at any time including, but not limited to, financial statements or information, receipts and/or invoices from vendors or service providers, and other such documentation as may be deemed necessary for United Way of Hernando County to review my application and the eligibility and allowability of any expenses described therein. Any additional documents or records requested must be provided. I am aware that failure to timely submit any additional supporting documents requested by United Way of Hernando County may result in my application being delayed or denied.
I understand and agree that any information provided in this Application that is not protected under an exemption to Chapter 119, Florida Statutes, is considered a public record and may be subject to a public records request under Florida Law. This includes information sent electronically via email.
I understand relevant information may be shared with or received from other agencies, including utility companies, my employer, landlords, mortgage companies, and the Clerk of Courts.
I am hereby notified pursuant to section 119.071(5), Florida Statutes, that social security numbers of applicants and household members are requested because this information has been determined to be imperative for the performance of the duties and responsibilities prescribed by law under this assistance program. This information is not required by state or federal law; however, social security numbers are necessary to determine eligibility for program services and specifically for the following purposes: to verify an applicant’s identity. A social security number collected pursuant to this notice can only be used by the United Way and Hernando County Government for the purpose specified above, and will not be disclosed to others unless required or authorized by Florida law.
I am responsible for providing accurate, complete and truthful information. I understand that if I provide incomplete or incorrect information or, if I falsify forms, I will have my benefits terminated, may be required to repay funds, and may be subject to a criminal investigation and possible prosecution.
I authorize the United Way of Hernando County to make benefit payments directly to my landlord, mortgage company, and/or utility/telecommunications supplier. I am aware that if my application is incomplete or supporting documentation is missing there may be a delay in process and/or my application may be denied.
I acknowledge and agree that in the event I am selected to receive an award from United Way of Hernando County that results in a direct disbursement of funds to me, I agree to retain records and documentation substantiating all expenditures using award funds for a minimum of five (5) years from the date of any award and to produce such records and documentation to United Way of Hernando County upon request. I acknowledge and agree that the United Way of Hernando County or its agent(s) or employee(s) shall be entitled to access any of my records and supporting documentation related to this my expenditure of award funds during regular business hours and upon request as may be necessary to conduct a full and complete audit of the records, to prevent fraud in this grant process or to ensure compliance with federal requirements. I shall fully cooperate with United Way of Hernando County or its agent(s) or employee(s) and shall timely respond to any requests for such records. At the end of such five (5) year period, I will allow United Way of Hernando County to copy all such records, if desired by United Way of Hernando County.
I certify and affirm that in the event I am selected to receive an award from United Way of Hernando County, no portion of the award to pay for or reimburse any expenses that have been or will be reimbursed by insurance or other private sources (including loans) or under any other local, state, or federal program. I acknowledge and agree that I will be required to repay any funds provided to me through the United Way of Hernando County CRA program that have been or will be reimbursed by any of the above-described sources.
I acknowledge and agree that in the event I am selected to receive an award from United Way of Hernando County, all funds from the award will be used solely to pay for or reimburse eligible expenses that were incurred as far back as March 1, 2020. In the event it is determined that any of the award funds were used for ineligible or unallowable expenses or I have otherwise failed to comply with all terms and conditions of the award, I acknowledge and agree that I will be required to repay the award to the United Way of Hernando County promptly upon demand. In the event the State of Florida or the federal government at any time demands the return of all or any portion of the award paid to me, I shall be solely liable for any such amounts and shall return the full amount of the award in question to United Way of Hernando County promptly upon demand.
I certify the information provided on and in connection with this application is true, accurate and complete. I understand that United Way of Hernando County is part of the Mid Florida Information Network (MFIN) and give permission for my personal data to be shared with other agencies in the network.
Under penalties of perjury, I declare that I have read the foregoing application and that the facts stated in it are true. I further understand that, pursuant to Section 92.525, Florida Statutes, a person who knowingly makes a false declaration thereunder is guilty of the crime of perjury by false written declaration, a felony of the third degree, punishable as provided in Sections 775.082, 775.083 or 775.084, Florida Statutes.