Support Services Intake Form First Name: ____________________________ Last Name:_______________________________ MI:_________ Mailing Address:___________________________________________________________________________________ City:_________________________________________________ State:_________ Zip Code:_____________ Phone:(_____)_______________________ Email: ___________________________________________________ Preferred contact method: [ ] Phone [ ] Email Date of Birth:____________________ Age:___________ Diversity & Inclusion Statement: Urban League of Metropolitan Seattle (ULMS) prides itself on practicing diversity and inclusion in everything we do. We prohibit discrimination based on age, race, disability, ethnicity, marital or family status, national origin, religion, gender, sexual orientation, veteran status, genetic information, gender identity, medical condition or any other characteristic protected by law. Our programs specialize in serving clients of diverse ethnicities, genders and include those who are homeless and/or post incarcerated. All are treated with the utmost dignity, respect, and courtesy. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. Race [Check all that apply] [ ] Asian American (please specify):________________ [ ] Black / African American [ ] Hawaiian or Other Pacific Islander [ ] Native American/Alaskan Native [ ] White [ ] Multi-racial (please specify):___________________ [ ] Other (please specify):________________________ [ ] Decline to respond Are you or an immediate family member a Veteran? [ ] No [ ] Yes. If yes, please list family member: IF YOU HAVE ANSWERED “YES” PLEASE CONTINUE. IF NO, PLEASE SKIP TO NEXT SECTION. Year entered military service: Year separated from military service: Military Branch: Discharge Status: Did you serve in any of the following theaters of operations? [ ] World War II [ ] Korean War [ ] Vietnam War [ ] Persian Gulf War(Desert Storm) [ ] Afghanistan (Operation Enduring Freedom] [ ] Iraq (Iraqi Freedom) [ ] Iraq (New Dawn) [ ] Other Gender [ ] Female [ ] Male [ ] Gender Non-conforming/Fluid/Non-Binary [ ] Prefer not to answer [ ] Prefer to self-describe: Do you identify as transgender? Yes [ ]No [ ] What is your current immigration status? [ ] U.S. Citizen [ ] Permanent Resident [ ] Refugee/Asylee [ ] Other Specify your primary language (the language spoken in your home): [ ] English [ ] Spanish [ ] Other: Do you need translation assistance? [ ] Yes: [ ] No [ ] Unsure Are you the Head of Household? [ ] Yes [ ] No [ ] Unsure Are you registered to vote in WA State? [ ] Yes [ ] No [ ] Unsure If you are a male aged 18 to 25, have you registered with Selective Service? [ ] Yes [ ] No [ ] Unsure [ ] N/A DEMOGRAPHICS PERSONAL INFORMATION Ethnicity [ ] Hispanic/Latin(x) [ ] Not Hispanic/Latin(x) [ ] Unsure [ ] Decline to respond VETERAN’S STATUS ULMS V5.0
Transcript
Support Services Intake Form
First Name: ____________________________ Last Name:_______________________________ MI:_________
Preferred contact method: [ ] Phone [ ] Email Date of Birth:____________________ Age:___________
Diversity & Inclusion Statement: Urban League of Metropolitan Seattle (ULMS) prides itself on practicing diversity and inclusion in everything we do. We prohibit discrimination based on age, race, disability, ethnicity, marital or family status, national origin, religion, gender, sexual orientation, veteran status, genetic information, gender identity, medical condition or any other characteristic protected by law. Our programs specialize in serving clients of diverse ethnicities, genders and include those who are homeless and/or post incarcerated. All are treated with the utmost dignity, respect, and courtesy. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment.
Race [Check all that apply][ ] Asian American (please specify):________________ [ ] Black / African American [ ] Hawaiian or Other Pacific Islander [ ] Native American/Alaskan Native [ ] White [ ] Multi-racial (please specify):___________________ [ ] Other (please specify):________________________ [ ] Decline to respond
Are you or an immediate family member a Veteran? [ ] No [ ] Yes. If yes, please list family member:
IF YOU HAVE ANSWERED “YES” PLEASE CONTINUE. IF NO, PLEASE SKIP TO NEXT SECTION. Year entered military service: Year separated from military service: Military Branch: Discharge Status:
Did you serve in any of the following theaters of operations? [ ] World War II [ ] Korean War [ ] Vietnam War [ ] Persian Gulf War(Desert Storm) [ ] Afghanistan (Operation Enduring Freedom] [ ] Iraq (Iraqi Freedom) [ ] Iraq (New Dawn) [ ] Other
Gender [ ] Female [ ] Male [ ] Gender Non-conforming/Fluid/Non-Binary [ ] Prefer not to answer [ ] Prefer to self-describe:
Do you identify as transgender? Yes [ ]No [ ]
What is your current immigration status? [ ] U.S. Citizen [ ] Permanent Resident [ ] Refugee/Asylee [ ] Other Specify your primary language (the language spoken in your home): [ ] English [ ] Spanish [ ] Other: Do you need translation assistance? [ ] Yes: [ ] No [ ] Unsure Are you the Head of Household? [ ] Yes [ ] No [ ] Unsure Are you registered to vote in WA State? [ ] Yes [ ] No [ ] Unsure If you are a male aged 18 to 25, have you registered with Selective Service? [ ] Yes [ ] No [ ] Unsure [ ] N/A
DEMOGRAPHICS
PERSONAL INFORMATION
Ethnicity [ ] Hispanic/Latin(x) [ ] Not Hispanic/Latin(x) [ ] Unsure [ ] Decline to respond
VETERAN’S STATUS
ULMS V5.0
How many people, including yourself, live in your household?
Do you have children? [ ] Yes, number of children: [ ] No
Number of children that reside with you: Specify ages:
What is your marital status? [ ] Married, living w/ spouse [ ] Married, not living w/ spouse [ ] Non-married partner [ ] Single, never married [ ] Widowed, divorced, legally separated
Are you or have you previously been a victim of domestic violence? [ ] Yes [ ] No [ ] Choose not to specify
If yes to domestic violence, are you currently fleeing? [ ] Yes [ ] No [ ] Choose not to specify
When did the experience occur? [ ] within 90 days [ ] 3 -6 months [ ] 7 months – 1 year [ ] Over 1 year
Which of the categories below best describes your current living situation?
Rent house or apartment with no subsidy Rent house apartment with subsidy
I and/or family member own the property Living with friend temporarily
Living with family temporarily Host Home (non-crisis)
Emergency shelter, incl. hotel/motel paid for w/ voucher Foster care home or foster care group home
Hotel or motel paid for without emergency shelter voucher Hospital or other residential non-psychiatric medical facility
Jail, prison or juvenile detention facility Residential project or halfway house w/ no homeless criteria
Work Release Safe Haven
Long-term care facility or nursing home Substance abuse treatment facility or detox center
Permanent housing for formerly homeless persons Transitional housing for homeless persons, including youth
Psychiatric hospital or other psychiatric facility Tiny House Village
Automobile / Car Van
RV/ Camper Homeless shelter
Outdoors / Tent Encampment Other:
Are you facing eviction or have you ever been evicted? [ ] Yes [ ] No If yes, does it appear on your credit report? [ ] Yes [ ] No [ ] Do not know How long have you been in your current living situation?
What is your current employment status? [ ] Employed full time [ ] Employed part time [ ] Temporary worker [ ] Seasonal worker [ ] Self-employed [ ] Unemployed [ ] Internship In the past year (12 months), how many different employers have you worked for? ___________________________
FILL OUT INFORMATION BELOW USING YOUR CURRENT JOB OR MOST RECENT JOB IF CURRENTLY UNEMPLOYED. Employer: Job title: Start date (mm/yyyy): End date (mm/yyyy, use N/A if still employed): How many hours per week do/did you usually work in that position? If applicable, why did you leave this job? [ ] Plant / division closed [ ] Quit [ ] Layoff [ ] Retirement [ ] Relocation [ ] Seasonal / temporary job ended [ ] Fired [ ] Better job [ ] Other (please specify):_______________
LIVING SITUATION
EMPLOYMENT
ULMS V5.0
Do you have a physical disability? [ ] Yes [ ] No If yes, is it expected to be of long-continued & indefinite duration, substantially impairing your ability to live independently? [ ] Yes [ ] No [ ] Unknown
Do you have a developmental disability? [ ] Yes [ ] No
Do you have a chronic health condition? [ ] Yes [ ] No If yes, is it expected to be of long-continued & indefinite duration, substantially impairing your ability to live independently? [ ] Yes [ ] No [ ] Unknown
Do you have a mental health condition? [ ] Yes [ ] No If yes, is it expected to be of long-continued & indefinite duration, substantially impairing your ability to live independently? [ ] Yes [ ] No [ ] Unknown
Do you have a substance abuse condition? [ ] No [ ] Alcohol abuse [ ] Drug abuse [ ] Alcohol & drug abuse If yes, is it expected to be of long-continued & indefinite duration, substantially impairing your ability to live independently? [ ] Yes [ ] No [ ] Unknown
Have you been convicted or pled guilty to a criminal offense within the last seven years? (Conviction will not bar you from services) [ ] Yes [ ] No If yes, please explain & indicate if offense was a misdemeanor or felony: ______________________________________________________________________________________________ Have you previously been incarcerated? [ ] Yes [ ] No If yes, when was the most recent release date?______
Are you currently on parole or probation? [ ] Yes [ ] No Do you have any open warrants which may interfere with training or obtaining employment? [ ] Yes [ ] No Do you have a valid driver’s license? [ ] Yes [ ] No If you have a valid driver license, do you own a working & reliable vehicle? [ ] Yes [ ] No If you have a working and reliable vehicle, is it insured? [ ] Yes [ ] No If you DO NOT have a valid driver license, is your license currently suspended? [ ] Yes [ ] No If you DO NOT have a valid driver license, have you sought assistance with relicensing? [ ] Yes [ ] No Will childcare issues prevent you from training / working or seeking work? [ ] Yes [ ] No
What is the highest level of education you have completed? [ ] Below high school [ ] Some high school, no diploma [ ] High school diploma [ ] GED certificate [ ] Associate’s degree [ ] Bachelor’s degree [ ] Master’s degree [ ] Technical/vocation diploma (please specify):____________________________________________________
Do you or your family have any of the non-cash benefits below?
Supplemental Nutritional Asst. Program (SNAP) Yes No TANF Childcare Services Yes No
Special Supplemental Nutrition Program for Women, Infants, & Children (WIC) Yes No TANF Transportation Services Yes No
Other non-cash benefit Yes No Other TANF-funded services Yes No
Do you or your family have health insurance? [ ] Yes [ ] No If yes, please indicate the coverage type(s): [ ] Medicare [ ] Medicaid [ ] Veteran’s Administration (VA) Medical Services [ ] Employer provided health insurance [ ] Health insurance obtained through COBRA [ ] Private pay health insurance [ ] State Children’s Health Insurance Program (SCHIP) [ ] State health insurance for adults
EDUCATION
BENEFITS & INSURANCE
DISABLING CONDITIONS & BARRIERS
ULMS V5.0
PROGRAM AWARENESS
EMERGENCY CONTACT
Please use the space below to describe how ULMS can best assist you:
How did you first hear about the Urban League of Metropolitan Seattle?
[ ] Black Prisoners’ Caucus (BPC) [ ] Village of Hope [ ] Flyer at community or government agency ( Specify agency): [ ] Friends or family [ ] Faith based organization (Specify organization): [ ] Online (Specify website): [ ] Community based organization or government agency staff (Specify agency): [ ] Other, specify:
Relationship to you:
Please provide an emergency contact who may be able to reach you.
Name:
Phone #: Email:
By signing below, I certify all information is true and correct to the best of my knowledge.
Applicant Name (Please print): ____________________________________________ Date: ____________________
Do you or your family have any of the cash benefits below? If yes, please indicate the amount: [ ] Earned Income: __________ [ ] Unemployment: __________ [ ] Worker's Comp: __________ [ ] Private Disability Insurance: __________ [ ] General Assistance: __________ [ ] TANF: __________ [ ] Alimony Received: __________
[ ] Child Support Received: __________ [ ] VA Service connected disability compensation: __________ [ ] VA Non-service connected disability compensation: __________ [ ] Social Security Disability Insurance (SSDI): __________ [ ] Social Security Insurance (SSI): __________[ ] Retirement Income from Social Security: __________ [ ] Pension/ Retirement from former job: __________ [ ] Other (please indicate): _____________________________
ULMS V5.0
Budget Worksheet
Step 1: Identify Income Sources
Source Expected per month Actual per month After tax wages After tax wages from spouse’s income Child support Food stamps Public assistance Social Security or Supplemental Security Income Tips, bonuses, cash from hobbies Unemployment compensation Other Total Monthly Income
Step 2: List Expenses
Source Expected per month Actual per month Car payment Cell phone Charitable donations Child support, alimony, spousal maintenance Childcare Clothes Credit cards Entertainment Gasoline Groceries and eating out Home maintenance Insurance (auto, homeowners, life, etc.) Other Personal (toiletries, hair, nails, etc.) Pet expenses Public transportation Rent/ mortgage payment Savings Emergency fund Savings for long term goals Tuition or school related fees Utilities Total Monthly Expenses
KING COUNTY HMIS - CLIENT CONSENT TO DATA COLLECTION AND ROI- Jan 2020
King County Homeless Management Information System (HMIS) CLIENT CONSENT FOR DATA
COLLECTION AND RELEASE OF INFORMATION
What is the HMIS? The HMIS is a data system that stores information about homelessness services. Bitfocus, Inc. manages the HMIS for King County. The purpose of the HMIS is to improve services that support people who are homeless to get housing, and to have better access to those services, while meeting requirements of funders such as the U.S. Department of Housing and Urban Development (HUD).
What is the purpose of this form? With this form, you can give permission to have information about you collected and shared with Partner Agencies that help King County provide housing and services. A current list of Partner Agencies is at http://kingcounty.hmis.cc/participating-agencies/
BY SIGNING THIS FORM, I AUTHORIZE King County and Bitfocus to share HMIS information with Partner Agencies. The HMIS information shared will be used to help me get housing and services. It will also be used to better understand and improve housing and homeless service programs. I understand that the Partner Agencies may change over time.
The information to be collected and shared includes: ● Name, birthday, gender, race, ethnicity, social security number, phone number, address● Basic medical, mental health, substance use, and daily living information● Housing Information● Use of crisis services, hospitals and jail● Employment, income, insurance and benefits information● Services provided by Partner Agencies● Results from assessments● My photograph or other likeness (if included)
BY SIGNING THIS FORM, I UNDERSTAND THAT:
● King County, Bitfocus and Partner Agencies will keep my HMIS information private using strict privacy policies.I have the right to review their privacy policies.
● There is a small risk of a security breach, and someone might obtain my information and use itinappropriately.
● If I have questions about my privacy rights, my HMIS information, or am concerned that my information hasbeen misused, I can contact my HMIS systems administrator at (206) 444-4001 x2.
● I can receive a copy of this Consent and the Client Information Sheet
● I may refuse to sign this Consent. If I refuse, I will not lose any benefits or services.
● This Consent will expire 7 years from my last HMIS recorded activity.
● I may revoke this Consent at any time in writing to:Bitfocus, Inc. ATTN: King County HMIS 5940 S Rainbow Blvd Ste. 400 #60866, Las Vegas, Nevada 89118-2507
KING COUNTY HMIS - CLIENT CONSENT TO DATA COLLECTION AND ROI- Jan 2020
● The revocation will take effect upon receipt, except to the extent others have already acted under thisConsent, and after Partner Agencies and King County have been notified so that revocation does not interferewith care or service coordination.
• My HMIS information may be further shared by the Partner Agencies to other agencies for care coordination,counseling, food, utility assistance, and other services.
• My HMIS information may be viewed by auditors or funders who review work of the Partner Agencies,including HUD, the Department of Veteran Affairs, the Department of Health and Human Services, and theWashington State Department of Commerce. I understand that the list of auditors and funders may changeover time.
• My HMIS information may be used to help evaluate the quality of services provided. It may also be used forresearch purposes that align with King County’s goals and mission.
IMPORTANT: Do not enter personally identifying information into HMIS for clients who are: 1) receiving services from domestic violence agencies; 2) currently fleeing or in danger from a domestic violence, dating violence, sexual assault or stalking situation; 3) are being served in a program that requires disclosure of HIV/AIDS status (i.e.; HOPWA); or 4) under 13 with no parent or guardian available to consent to enter the minor’s information in HMIS.
If one of these situations applies to you, DO NOT agree to have your personal identifying information collected
CLIENT* INFORMATION:
Client Name:
Client Date of Birth:
* Please use one form for each member of a household (including one form for each minor child).
SIGNATURE:
Signature of Client or Representative authorized by law:
PRINTED NAME
Date
Authority of representative to sign on behalf of the client: ☐ - Parent ☐ - Legal Guardian ☐ - Court Order ☐ - Other:
__ _ Date
_ _ (Witness Staff & Agency)
For Agency Use Only (to be kept on file at agency):
Client Opted Out (Refused Consent) (Staff/Agency Initials)
ULMS V5.0
Authorization & Disclosure Agreement
I authorize the Urban League of Metropolitan Seattle and its pertinent employees to: a) Discuss and negotiate my/our housing application or housing status with landlords, rental companies, transitional
housing programs, shelters, or any location meant for habitation;b) Discuss and negotiate my job application or job status with employers or prospective employers;c) Be able to obtain supplemental information from the Department of Corrections, City of Seattle, United Way, or
duly designated third party contractors and/or agency to help assist my situation and to verify information;d) Share statistical information about my situation with City of Seattle, United Way, Housing & Urban Development
(HUD), Homeless Management Information System (HMIS), NeighborWorks® America, Port of Seattle,Department of Corrections, or other government funders in conformance with the privacy act;
e) Obtain my credit report and review my credit file for Housing Search Assistance in pursuit of rental or otherhousing possibilities and informational inquiry purposes' such as Project Reinvest Financial Capabilities;
f) Obtain my criminal background in pursuit of Housing Search Assistance, Job Development, or for informationalinquiry purposes;
g) Permit NeighborWorks® America, City of Seattle, United Way, HUD, HMIS or its authorized representative, dulydesignated third party contractors and/or agents (for program evaluation purposes) to follow-up with me and/orretrieve and review client credit information and records, including credit reports to two (2) additional timesbetween client intake date and date of case closure, to conduct follow-up interviews/communications withclients for program evaluation purposes.
Additionally, I attest to the following statements: • I understand that the Urban League of Metropolitan Seattle provides various programs and counseling. After
I receive such counseling or finish such a program, I will receive recommendations for housing oremployment including referrals to other agencies as appropriate.
• I understand that the Urban League of Metropolitan Seattle is required to share some of my personalinformation and testimony for monitoring, compliance, and evaluation.
• I acknowledge that I have read and received a copy of the Privacy Policy and Disclosure.• Authorization is further granted to use a photocopy of my signatures below to obtain information regarding
any of these items.
By accepting the Urban League of Metropolitan Seattle programs, services and/or counseling, I acknowledge that I are no way obligated to participate in any other program, service, and/or counseling offered by the agency, or to use the services of any of their partners or associates.
I understand that any intentional or negligent representations of the information contained in this form may result in civil liability and/or criminal liability under the provisions of Title 18, United States Code, Section 1001.
Signature of Applicant Date Name of Applicant (Print) Last 4 of Social Security #
Your signature allows the release of this information, housing, and job placement data to the Urban League of Metropolitan Seattle staff for program monitoring, verification, additional data collection, and evaluation purposes. Your personal information will not be provided to any outside person or agency except where needed to determine eligibility for Urban League programs. Information provided on this application will not affect any benefits you are already receiving from other agencies.
ULMS V5.0
Privacy Policie
s and Practices The Urban League of Metropolitan Seattle values your trust and is fully committed to the responsible management, use, and protection of your personal information. This notice describes our policy regarding the collection and disclosure of any personal information acquired. Personal information, as used in this notice, means information that identifies an individual personally and is NOT otherwise public information. Personal information includes your personal financial information such as credit report, credit history, financial assets, bank accounts, financial debts, and income and employment history. It is also subject to your social security number and other information that you have provided to us on any applications or forms that you may have submitted.
Information we collect: We will collect your personal information to support our housing and counseling program to aid you in shopping for and obtaining a home mortgage from a conventional lender. We will collect personal information about you from the following sources:
• Information that we receive from your completed applications or forms,• Information about your transactions with us, our affiliates or others,• Information we receive from a consumer reporting agency, and• Information that we receive from personal and employment references.
Information we disclose: We MAY disclose the following sort of personal information about you:
• Information we receive from your applications or other forms, such as name, address, social security number,employer, occupation, assets, debts, and income,
• Information about your transactions with us, our affiliates or others, such as your account balance, paymenthistory and parties to your transactions,
• Information we receive from a consumer reporting agency, such as your credit bureau reports, our credithistory, and creditworthiness.
To whom do we disclose: We MAY disclose your personal information to the following types of unaffiliated third parties:
• Financial service providers, such as companies engaged in providing home mortgage or home equity loans,• Others, such as non-profit organizations involved in community development, but only for program review,
auditing, research, and oversight purposes.We may also disclose personal information about you to third parties as permitted by law. Before sharing personal information with unaffiliated third parties, except as described in this privacy policy, you will have the opportunity to direct that such information NOT be disclosed.
Confidentiality and security We restrict access to personal information about you to those of our employees who NEED to know that information to provide products and services to you and to help them for their jobs, including underwriting and servicing of loans, down payment assistance, making loan decisions, aiding you in rental and financial counseling.
Initial(s): Page 1 of 2
ULMS V5.0
Confidentiality and security continuedWe maintain physical and electronic security procedures to safeguard the confidentiality and integrity of your personal information in our possession and to guard against unauthorized access. Our safeguards comply with federal regulations to protect your personal information.
Directing us NOT to make disclosure to unaffiliated third parties If you prefer that we DO NOT disclose personal information about you to unaffiliated third parties, you may opt-out of such disclosures; that is, you may direct us NOT to make those disclosures (other than permitted by law).
If you wish to OPT-OUT of disclosures to unaffiliated third parties other than nonprofit organizations involved in community development please check:
___ Limit disclosure of personal information about me to unaffiliated third parties other than nonprofit organizations involved in community development.
If you wish to OPT-OUT of disclosures to nonprofit organizations involved in community development that are used only for program review, auditing, research, and oversight purposes please check: ___ Limit disclosure of personal information about me to nonprofit organizations involved in community development that are used only for program review, auditing, research, and oversight purposes.
Statement of understanding and agreement By signing below, you are stating that you have read, understand, and agree to the Urban League of Metropolitan Seattle's Housing and Financial departments' Privacy and Policy and Practices. If you prefer that we DO NOT disclose personal information about you to unaffiliated third parties, you may direct us NOT to make those disclosures (other than that permitted by law) by completing the Privacy Choices Form attached. Applicant Name:
Address:
City: State: Zip Code:
Home Phone: ( ) Alt. Contact: ( )
Applicant Signature:
If you have checked any of the boxes about, please give this form to your counselor or mail it in a stamped envelope to: Urban League of Metropolitan Seattle
105 14th Ave Suite 200, Seattle, WA 98122
Please allow approximately 30 days from our receipt of your Privacy Choices Form for it to become effective until you request a change.
Page 2 of 2 Initial(s):
ULMS V5.0
Authorization to Take and Use Photographs / Video Waiver and Release of Claims
I hereby grant the Urban League of Metropolitan Seattle, its directors, officers, employees, agents, and designees (collectively "ULMS") non-revocable permission to capture my image and likeness in photographs, videotapes, motion pictures, recordings, or any other media (collectively "Images"). I acknowledge that ULMS will own such Images and further grant ULMS permission to copyright, display, publish, distribute, use, modify, print and reprint such Images in any manner whatsoever related to ULMS business, including without limitation, publications, advertisements, brochures, web site images, or other electronic displays and transmissions thereof. I further waive any right to inspect or approve the use of the Image by the ULMS before its use. I forever release and hold the ULMS harmless from any and all liability arising out of the use of the Images in any manner or media whatsoever, and waive any and all claims and causes of action relating to the use of the Images, including without limitation, claims for invasion of privacy rights or publicity.
I have read and received a copy of the Urban League of Metropolitan Seattle's Image Authorization.
Signature of Applicant Date
Name of Applicant (Please Print)
ULMS V5.0
Release of Information for a Criminal Background Check
I understand the Urban League of Metropolitan Seattle will use the services of a Consumer Reporting Agency and/or Washington State Patrol to perform a Criminal History Background check as part of the procedures for processing my application for employment, residency, or part of a Criminal Records Expungement Workshop.
I understand that the Consumer Reporting Agency and/or Washington State Patrol will conduct an investigation that verifies my social security number and includes obtaining information regarding past employment and criminal background. The Consumer Reporting Agency and/or Washington State Patrol will track my counties of residence to search for criminal records.
I also understand that before I am denied residency or employment based on information obtained in the report, I will receive a copy of the report and a written description of my rights under the Fair Credit Reporting Act.
I understand that if I disagree with the accuracy of any information in the WA State Patrol report, I have the option to request that the information be corrected pursuant to RCW 10.97, the Washington State Criminal Records Privacy Act.
I understand that the information contained in the Criminal History Background Check will only be available to those persons involved in making employment or residency decisions, or instructors of the Expungement Workshop.
I hereby consent to the Criminal History Background Check as described above, and authorize the Urban League of Metropolitan Seattle to produce reports concerning my background as stated above.
Full Name (First, Middle I., Last, Please print):
Date:
Signature of applicant:
Date of birth:
ULMS V5.0
Credit Report Authorization
Date:
I authorize the Urban League of Metropolitan Seattle, a HUD certified counseling agency, to order a consumer credit report from CoreLogic Credco or American Reporting Company (ARC) for pre or post-purchase counseling and / or rental referral purposes or assisting me with a mortgage default and/or foreclosure resolution.
I further authorize all relevant entities to accept a copy of the document as permission to release such information to the Urban League of Metropolitan Seattle.
I also give consent for you to discuss my case with the Urban League of Metropolitan Seattle’s representative(s) listed below, as they are in the process of helping me address my current credit and financial condition.
PLEASE PRINT CLEARLY
Applicant
Full name:
Address:
City: State: Zip:
Date of Birth: Age:
Social Security:
Signature:
Social Security Number:
Urban League of Metropolitan Seattle Representatives:
Linda Taylor Qiana Tyesky Helen GainesVP of Housing & Financial Director of Housing Homeless Outreach ProgramsEmpowerment Manager
Elvira Hernandez Natalie Lockhart Angela Williams Justin RoeuthHousing Counselor Housing Counselor Financial Empowerment Data Entry
Coach Coordinator
ULMS V5.0
Please indicate size of household: Number of Dependents:
FY 2020 HUD Income Categories Instructions: Find the column for the number of people in your household. Go down that column until you find the income range for your
annual gross income this year. Look to the left to see what that row is labeled. That is your income category.
1
Person
2
Persons
3
Persons
4
Persons
5
Persons
6
Persons
7
Persons
8
Persons Household Category
Extremely Low Income
(30% of Median Income)
□ Up to
$25,100
□ Up to
$28,650
□ Up to
$32,250
□ Up to
$35,800
□ Up to
$38,700
□ Up to
$41,550
□ Up to
$44,400
□ Up to
$47,300 □ □ □ □ □ □ □ □
Low Income $25,101 $28,651 $32,251 $35,801 $38,701 $41,551 $44,401 $47,301 (50% of Median Income) to to to to to to to to
How information is used All demographical data on this intake is used for statistical purposes only. Your personal information is used by ULMS to keep in touch with you and provide additional services you may be interested in.
Confidentiality and security We restrict access to personal information about you to those of our employees on a need-to-know basis to provide products and services to you and to assist them to do their jobs, including underwriting and servicing of loans and/or down payment assistance, making loan decisions, aiding you in renting or obtaining loans from others, and financial counseling. We maintain physical and electronic security procedures to safeguard the confidentiality and integrity of personal information in our possession and to guard against unauthorized access. We use locked files, user authentication and detection software to protect your information. Our safeguards comply with federal regulations to guard your personal information.
By signing your signature below, you are stating that you have read, understand and agree to how the information you disclosed on this form is being used and the Urban League’s Confidentiality and Security statement above. Thank you for your interest and participation in the Urban League of Metropolitan Seattle's Housing program(s).
SIGNATURE DATE
FOR OFFICE USE ONLY:
CLOSING DATE _ _- _ - _
COMMENTS
Please mark the annual income of your household. This figure includes all public assistance, disability and other non-wage grants of payments. Figures below are based on HUD Income Categories.
