Economic Mobility Services Application

WELCOME

Ada Jenkins Center Economic Mobility Intake Form
Thank you for reaching out to the Ada Jenkins Center. We are here to support you with a range of programs designed to assist individuals and families facing financial hardships. Please take a few moments to complete this intake form so that we can better understand your needs and guide you to the appropriate resources.

About Our Programs:
- Financial Assistance:
  The Ada Jenkins Center offers limited funding to help residents of Cornelius, Davidson, and Huntersville who are experiencing financial hardship. Assistance is available for households with an income at or below 60% of the area median income (AMI). We can provide support for essential needs such as rent, mortgage, utilities, and childcare.
- Economic Mobility Program:
  If you or your family are currently homeless (residing in emergency or transitional shelters or living on the street), our Economic Mobility Program may be able to assist you. The goal is to help you obtain or maintain permanent housing, with care management and/or temporary assistance to help you secure and maintain stable housing.
By completing this intake form, we will better understand your situation and determine how we can best support you. Thank you for taking the time to provide this information, and we look forward to assisting you in your journey toward economic stability and housing security.

Directions:
- Previous Services: Let us know if you have previously received services from the Ada Jenkins Center.
- Please fill out all sections accurately and completely to ensure we can process your application efficiently.
Documentation: To determine eligibility and process requests for assistance, we will require you to provide:
- Picture ID for all adult members of the household
- Active lease or mortgage agreement
- Current rent ledger or statement from the property management company showing your outstanding balance
- Utility bill in the name of a household member for most recent service cycle (if requesting assistance with utility payments)
- Invoice for childcare verification (if requesting assistance with childcare payments)
- Proof of income for all adult household members for the last 30 days.
Previous Services:*

I have previously received services from the Ada Jenkins Center.This is my first time seeking assistance from the Ada Jenkins Center.
Program Options (Select all that apply): In addition to Economic Mobility

Food Pantry ReferralFree Tax PreparationClothing ReferralLearn Works (Education)Other

Financial Information

Current Employment Status (for all household members over 18):*
If unemployed, provide the date unemployment began:

MonthDayYear
Date
Are you currently seeking employment?
Are you currently receiving unemployment benefits?

	Answer
Name of Employer(s):
Position(s):
Length of Employment:
Average Monthly Income:

Please provide the total monthly income for your household from the following sources:*

	Income Amount $
Employment Income (combined):
Social Security Benefits (SSI, SSDI):
Child Support/Alimony:
Unemployment Benefits:
Food Assistance (SNAP):
Housing Assistance:
Other Income Sources (specify):
Total Monthly Income:

Please provide the total monthly expenses for your household from the following area(s):*

	Expense Amount $
Rent or Mortgage Payment:
Utilities (Electricity, Gas, Water):
Childcare Expenses:
Food Expenses:
Transportation (Car Payment, Gas, Insurance, Public Transit):
Healthcare/Medical Expenses (including insurance premiums):
Loan Payments (Personal, Car, etc.):
Other Monthly Expense:
Credit Card Payments:
Total Monthly Expense:

Household Information

Please provide the following information regarding the individuals that reside in your household.
Does every adult in the household have a valid ID?*
How many children are in the household?*
Any individual under the age of 18 years old

Household Members:

	Name	Gender	Date of Birth	Race	Ethnicity
Household Member
Household Member
Household Member
Household Member
Household Member
Household Member
Household Member

Eviction Information

Please complete the following information:

	Answer
Do you or anyone in your household have any past evictions?
If you have an eviction, is it paid off?
If not paid off, are you actively paying it off?

How much did/do you owe towards the eviction?
Amount owed:

Utility Information

Please complete the following information:

	Answer
Do you or anyone in your household owe money to any utility companies (water, gas, electric)?
Which company/companies?

How much did/do you owe towards the utility company(s)?
Amount owed:

Pet Information
Does anyone in your household have a pet?
If so, how many?
Amount owed:
If a dog, what breed?

Savings Information
Do you have any savings to contribute towards moving costs? (This includes security deposit, moving fees, and utility connections.)
If yes, how much?
Amount saved:

Legal and Documentation

To complete your application for financial assistance or rapid rehousing, please provide the following documents. These are required to verify your identity, income, and current housing situation. Ensure that all documents are up-to-date and legible.
Important Instructions:
All documents should be recent (within the last 90 days) and clearly show the necessary information (names, addresses, amounts, etc.).

Please scan or take clear photos of your documents to ensure they are readable.
If you are missing any documents, please provide them as soon as you are able to.

Required Documentation:

Picture ID:Please provide a copy of a valid photo ID for all household members. Acceptable forms of ID include:
- Driver’s License
- State ID Card
- Passport
Active Lease or Mortgage Agreement: Submit a copy of your current lease or mortgage agreement, showing your name and address. This is necessary to confirm your housing situation.
- Current Rent Ledger or Statement
- Provide a rent ledger or a statement from your property management company, indicating your outstanding rent balance, if you are requesting assistance with rent or mortgage payments.
Utility Bill: If you are requesting assistance with utility payments, submit the most recent utility bill in the name of a household member. This bill should show the service dates and the amount owed.

Invoice for Childcare Verification: If you are requesting assistance with childcare payments, include:
- A child care invoice for the most recent billing period.
Please provide a copy of a valid photo ID for all household members.

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Active Lease or Mortgage Agreement: Submit a copy of your current lease or mortgage agreement, showing you.

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Please provide a copy of a utility bill and/or invoice for childcare verification.

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Please provide a copy of the bill and/or invoice you are seeking assistance for:

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Please provide any additional documents for income verification: paystubs, bank statements, or W9/1099)

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Consent and Agreement

Thank you for providing the necessary information. Before proceeding, please carefully review the following sections regarding the release of your information, communication, and agreement to the program terms. Your consent ensures that we can coordinate services effectively and efficiently to meet your needs.
Release of Liability:
On behalf of myself and my household members, I hereby release and hold harmless The Ada Jenkins Center and its employees, agents, and partnering agencies from any and all liabilities, costs, or consequences related to the services provided, including but not limited to injury, death, damage, or loss of property. I understand that this agreement applies to any act or failure to act by The Ada Jenkins Center, its employees, or agents. I agree not to hold The Ada Jenkins Center or its employees or agents responsible for damages, and I will not pursue any legal action against them.

Purpose of Services:
I understand that the information provided by The Ada Jenkins Center and its partnering agencies is for educational purposes only and is not a substitute for expert consultation or advice. The services are intended to educate and inform families about resources such as financial literacy, employment skill-building, educational opportunities, life skills, and budgeting to strengthen families and promote stability.
I hereby agree to hold harmless and waive any rights or causes of action against The Ada Jenkins Center and partnering agencies for any financial or other damages resulting from the services provided.

Term of Agreement:
This agreement will remain in effect from the date of signing until my departure or the termination of the services provided.

Confidentiality and Data Consent:
I understand that my information will be kept confidential, and no information will be shared unless it is essential to assisting me. The Ada Jenkins Center will request my permission before releasing any information to partner organizations or other providers. Additionally, I authorize the entry of my information into The Ada Jenkins Center’s computer database. This consent is valid for one year and may be revoked at any time by submitting a written request.

Limits on Confidentiality:
- I acknowledge that certain situations require disclosure of confidential information by law. These include:
- If I am deemed a danger to myself or others.
- If a child under the age of 18 reports or is suspected of being a victim of abuse (physical, emotional, or sexual) or neglect.
Authorization for Release of Information
I authorize The Ada Jenkins Center and other individuals, agencies, or organizations listed within this application to release and receive information relative to obtaining services on my behalf and for my dependents under 18. This information may include service plans, benefits eligibility, and health-related data. The consent remains valid from the date of consent, not exceeding one year.

Agreement and Acknowledgment:
By signing below, I confirm that I have read and understood the above information, and I have had the opportunity to ask any questions. I agree to the terms and conditions as outlined in this Consent and Agreement.
Authorization Information in HMIS
I understand that my personal information will be entered into the Homeless Management Information System (HMIS), a secure database used to track services provided to clients. I consent to the following:
- My information will be shared only with authorized partner agencies within the HMIS network to assist with service coordination and referrals.
- My information will be used for reporting and analysis purposes to improve service delivery while maintaining confidentiality.
Homelessness History
It may be necessary to document your homeless history to see if you are eligible for specific community programs. To provide this information, the Michigan Coalition Against Homelessness(MCAH), the NC HMIS lead agency, requires your explicit consent to view data recorded in NC HMIS and complete a housing history document.

Please review entire document (Click Here)
I ,First and Last Name give permission for the following information:
- I give permission for MCAH (NC HMIS Lead Agency) to complete the housing history document and give it to my case manager.
- I give permission for information about me recorded in HMIS to be shared with partner agencies to better coordinate services for me and my dependents.
Please select if you DO NOT give permission for any of the following:

I do not give permission for information about me recorded in HMIS to be shared with partner agencies to better coordinate services for me and my dependents.NO, I do not give permission for MCAH (NC HMIS Lead Agency) to complete the housing history document and give it to your case manager.
Authorization to Communicate via Text
I authorize the Ada Jenkins Center staff to send text messages to my mobile phone regarding my housing and assistance services. I understand that standard text messaging rates may apply based on my service plan.*

I agree to receive text messages.I do not agree to receive text messages.
Certifications and AgreementBy signing below:*

I certify that all information provided in this form is accurate and true to the best of my knowledge.I understand that a copy of this form may be shared with other entities as needed to verify eligibility for the Ada Jenkins program or other services.
Date*

MonthDayYear
Date

Notice: If you have not uploaded all the important documents please click "SAVE" prior to submitting your application.
Should be Empty:

WELCOME

Personal Information

Financial Information

Household Information

Legal and Documentation

Consent and Agreement

Authorization Information in HMIS

Authorization to Communicate via Text