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� YOry, <br />�l <br />CATHOLIC <br />h; <br />CHARITIES <br />OFORANGECOMY <br />Safely Home in Santa Ana <br />Eviction Prevention Program <br />Application (PaLye 2 of 2) <br />Assistance Request: <br />❑ Rent (Eviction Prevention) <br />Do you have an eviction (3-day) notice? ❑ Yes ❑ No <br />If no, have you ever received a 3-day notice? ❑ Yes ❑ No <br />If yes, how many times? <br />Emergency' <br />What is your unexpected emergency situation that is preventing you from paying your <br />rent/bills? <br />How will you pay your rent/bills next month? <br />Client's Signature: Date: <br />Consent and Release of Information: By signing this form, I, the applicant(s), certify that all information <br />provided is true and accurate to the best of my knowledge. I authorize the City of Santa Ana (COSA), <br />Catholic Charities of Orange County (CCOC) and The Salvation Army of Orange County (TSA) to share <br />basic household information between themselves, such as my name and date of birth, to prevent <br />duplication of services. I also authorize COSA, CCOC and TSA to make inquiries as necessary to verify the <br />accuracy of the statements made, including, but not limited to, income. I understand that my <br />demographic information (household size, income level, previous homelessness, amount of assistance <br />provided, veterans status) will be shared on a quarterly basis with COSA for reporting purposes, but my <br />name, date of birth, residency status, address, and any other personally identifiable information will <br />not be shared outside of the agencies listed herein. <br />❑ I give consent for COSA, CCOC and TSA to share basic household information with other Social Service <br />and voluntary organizations participating in client management services in order to coordinate available <br />services. <br />COSA, CCOC and TSA are committed to respecting your privacy and to using the information solely to <br />prevent service duplication between the agencies and to provide appropriate referrals to additional <br />supportive services when required. <br />For Office Use On/y. <br />o Unable to Assist: <br />o Do not qualify ❑ No Funds available ❑ Already received assistance in the past <br />Ei Do not have all required documentations <br />Ei Referred to/Notes: <br />10 <br />