Thank you for your interest in
Community Action’s Weatherization Program
Eligibility is based on your household’s income 12 months prior to your application. Everyone in the
household over the age of 18 must provide income documentation. If the person did not receive income 12
months prior to the application, a notarized statement is required stating that the person was unemployed during
those last 12 months and did not receive income. There are several forms of income that are counted as
household income, and we have included an information sheet outlining the types of income and the
documents that need to be included with your application to verify your income. Please send copies of
verification documents, not originals, as we will not return any materials to you.
Please fill out every form that asks for information. Also, note that some forms are double sided.
We prioritize our applications based on criteria required by our funding sources. Look below:
1. People with disabilities over 60
2. People over 60
3. People with disabilities
4.
5.
6.
Native Americans
People with children under 6
All others income-eligible
Those with a high priority (elderly and people with disabilities) will be served before applicants with a lower
priority.
The term "disabled person" means any individual who: has a physical or mental disability which
constitutes or results in a substantial handicap to the individual’s employment; or has had a record of
having, or is regarded as having a physical or mental impairment which substantially limits one or more
of the individual's major life activities; or has a disability which would make the individual eligible to
receive disability insurance benefits or Supplemental Security Income from the Social Security
Administration or developmentally disabled assistance from the Department of Health and Human
Services.
Please mail or deliver your completed application and verification materials to us. We will review the
application, work with you to provide any missing information, and then determine your eligibility and priority
status. At that point, we will contact you about the next steps.
If you have any questions regarding the application or materials required, please feel free to contact
the Weatherization Clerk at anytime, (402) 875-9365
Income Eligibility for Community Action’s Weatherization Program
Applicant Name: _________________________________________________________
By signing this form I attest that all of the income of all adults (18 years or older) living in my household is
attached and has been honestly reported.
Signature: _________________________________________
Date: _________________________
In order to qualify for FREE Weatherization, the client must meet the income guidelines listed below:
Number of members in Household
Maximum Gross Annual Income
1
$16,755
2
$22,695
3
$28,635
Add $5,940 for each additional person
An applicant is automatically eligible if he/she receives:
LIHEAP (Low Income Home Energy Assistance Program) Must include with application the eligibility letter
from LIHEAP dated within the last 12 months.
OR
TANF (Temporary Assistance for Needy Families) Must include with application the letter stating monthly
allotment or copy of a check.
OR
SSI (Supplemental Security Income) Must include with application the letter stating monthly allotment or
copy of a check.
_____________________________________________________________________________________
Types of reportable income
(income before any deductions):
Acceptable proof of reportable income:
If your household had this type of
reportable income in the last 12
months, please attach copies of
acceptable proof.
W-2 s for 2011 along with pay stubs from
Money, wages and salaries before any
January 1, 2012 to date of application
–
deductions
OR-Pay stubs showing the last 12 months of
earnings –OR—
Pay stubs from the last 3 months (we will
assume this represents regular income for the
past year and multiply the total for 3 months by
four to get a yearly income.)
Net receipts from non-farm or farm
self-employment (receipts from a
Most recent 1099 Tax Form for 2011 and
person’s own business or from an
Statement of Account showing net income from
owned or rented farm after deductions
January 1, 2012 to date of application.
for business or farm expenses)
Letters stating monthly allotments for:
Regular payments from:
Social Security
Railroad Retirement
Unemployment Compensation
Strike benefits from union funds
Worker’s Compensation
Veteran’s payments
Training Stipends
Social Security Retirement Benefits, Social
Security Disability Insurance
Railroad Retirement Board Benefits
Unemployment Compensation
Strike Benefits from Union
Worker’s Compensation
Veteran’s Benefits
Training Stipends
Alimony
Military Family Allotments
Alimony
Military Family Allotments
Private Pension
Government
Employee
Pensions
(including military retirement pay)
Regular insurance or annuity payments
Letters or pension statements noting monthly
allotments for each type of income.
Dividends and/or interest
Bank statements or investment statements from
the months identified.
Net rental income and net royalties
Profit and Loss Statement for the months
identified for rental properties owned by the
applicant.
Statements of royalties received for the months
identified.
Check stubs; letters from estate attorney or
administrator documenting disbursements to
you.
Statements from casinos showing total wins and
losses for the year.
–OR-A self-reported record of all wins and losses for
the prior 12 months.
–OR-W-2’s from casinos.
–OR-Tax return for 2011, only for applications made
through March, 2012 along with documentation
for wins/losses from January, 2012 to date of
application.
Periodic receipts from estates or trusts
Net gambling or lottery winnings
For Office Use Only:
Date Verified: _________________________________________
Clerk Signature: _________________________________________ Date:
Approved by: ____________________________________________ Date
Community Action’s Weatherization Program
STATEMENT of Participant RIGHTS & RESPONSIBILITIES
Each agency participant is entitled to be treated with dignity and respect. In return, each participant has
the responsibility to treat others with dignity and respect.
As a participant of Community Action’s Weatherization Program, you have the RIGHT:
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To receive professional services
To be treated with dignity which includes freedom from:
 physical violence or contact which could cause physical or emotional damage
 demeaning comments or actions made on the basis of race, religion, national origin, gender,
mental or physical disability, marital status, sexual orientation, age or income status
 sexual harassment of any type
To expect program staff and contractors to respect your confidentiality
As a participant in Community Action’s Weatherization Program, you have the RESPONSIBILITY:
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To be honest in providing proof of eligibility and priority status
To treat program staff and contractors with dignity which includes freedom from:
 physical violence or contact which could cause physical or emotional damage
 demeaning comments or actions made on the basis of race, religion, national origin, gender,
mental or physical disability, marital status, sexual orientation, age or income status
 sexual harassment of any type
To provide a workspace supporting safe work in the home and on including removal of
pets and any items that limit access to the work area (boxes, clutter, etc.)
To work cooperatively with program staff and contractors to schedule inspections and work in a
timely manner.
To provide access to your home during weekdays between the hours of 8 a.m. and 5 p.m. or at
another time agreed upon with program staff and contractors.
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AGREEMENT AND RELEASE
I have read and understood the Participants Rights and Responsibilities explained above and agree to abide
by these standards.
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If I feel my rights as outlined in this Statement have been violated, I will contact the Weatherization Director
at Community Action to discuss my concerns.
I also understand that my violation of the responsibilities outlined in this Statement, or violation of the
program rules, may result in termination of services.
Signature _______________________________________________Date
(Participants Signature)
Community Resources
General Assistance- 2-1-1 provides free and confidential information and referral. Call 2-1-1 for help with
food, housing, employment, health care, counseling and more.
Nebraska Low Income Energy Assistance Program (LIHEAP)
Available to help those with limited incomes offset the cost of heating and cooling their homes. The best way to
receive help is to contact your county's Department of Social Services.
ACCESS Nebraska
Nebraska Department of
P.O. Box 95026
Health and Human Services
Lincoln, NE 68509-5026
1050 ‘N’ Street, Suite 250
www.accessnebraska.ne.gov
P.O. Box 95026
(800) 383-4278
Lincoln, NE 68509-5026
(402) 323-7455, if calling from Lincoln
(402) 471-3121
Urban Development- Emergency Repair Loan Program
Phone: (402) 441-7864
 For emergency repair, such as replacing furnaces, water heaters, dangerous wiring, water services,
sewer lines, cave-in foundations, leaky roof, etc.
Nebraska Energy Office – Low Interest Loans
Phone: (402) 471-2867
 Nebraska Dollar and Energy Saving Loans are offered statewide by the Nebraska Energy Office and
the state's lending institutions. The simple interest rate is 5%* or less. [*final annual percentage rate
(APR) may vary by lender and loan fees charged]. Many common home, building or system energy
improvements qualify for financing. Visit their website for more details: www.neo.ne.gov Click on
“Loans” under the Services category.
Energy Efficient Housing Loans - The Nebraska Energy Office is offering 2.5% Dollar and Energy Saving
Loans through eligible Nebraska lenders for the construction of single family, detached dwellings located in
Nebraska. Call (402) 471-2867 for more information.
Aging Partner Home Handyman Program
Phone: (402) 441-7070, Toll Free: (800) 247-0938
 Do you need help with home maintenance and minor repairs? Our Handymen are typically retired
workers who have learned home repair from many years of personal experience. Although Home
Handyman can take a variety of projects, it must be noted that they do not undertake large projects
such as remodeling, roofing, flooring, HVAC or large painting jobs.
Lincoln Electric Systems (LES) in which participating contractors can provide you an immediate LES Green
Credit when you purchase eligible equipment and / or services from them on or after February 1, 2011.
Incentives are exclusively available to LES customers with accounts in good standing on a first-come, first
serve basis. The program will close December 2, 2011, or when funds are depleted, whichever comes first.
Check their website at www.les.com for information on Whole House Sealing and Insulation and High
Efficiency Heat Pump and Air Conditioner programs.
League of Human Dignity
The League of Human Dignity is an organization of people concerned about the rights and quality of life for
people with disabilities. Is it difficult for you to get around? Or get things done? Home modification may be the
solution. A ramp, porch, lift, stair lift, grab bars, hand rails, wider doorways, accessible tubs and showers, or
lowered sinks and counters could allow you to live independently while remaining in your own home. For more
information contact the Lincoln Center for Independent Living at: (402) 441-7871.
DEPARTMENT OF ENERGY PROGRAM CERTIFICATION
WEATHERIZATION PERMISSION FORM
Case No. _________________
I, ___________________________________________certify that I am the owner/authorized agent for the property at
(Owner/Landlord’s Printed Name)
____________________________________________________________
(Applicant’s Address)
I, as landlord/owner/authorized agent, do authorize inspection of the above noted property by Community Action Partnership, and
Department of Energy Federal and State inspectors.
I understand that the Weatherization procedure that will be employed on the property will be done under an approved and generally
accepted procedure. I hereby give my permission to allow Weatherization of the above listed property by Community Action
Partnership I recognize that this may include inspection/repair to the furnace.
I further agree that if the above named property is presently occupied by a Nebraska Low-Income Weatherization Assistance Program
eligible client, I will not increase the rent payments incurred on this individual due to the work performed on said property by
Community Action Partnership. In addition, I will not evict or remove the tenant from the dwelling for a period of one (1) year so long
as he/she complies with all ongoing obligations and responsibilities owed the landlord.
I, AS OWNER OR AUTHORIZED AGENT FOR THE PROPERTY DESCRIBED ABOVE, DO HEREBY GIVE
PERMISSION FOR THE PROPERTY TO BE WEATHERIZED ACCORDING TO THE DEPARTMENT OF ENERGY
(DOE) STANDARDS AND REGULATIONS. AS PART OF THIS SERVICE THE HEATING SYSTEMS WILL RECEIVE
AN INSPECTION, TUNE-UP AND CLEANING. THE WEATHERIZATION SERVICES AND THE INSPECTION, TUNEUP AND CLEANING WILL BE PERFORMED AT NO COST TO THE OWNER.
HOWEVER, IF IT IS DETERMINED BY A LICENSED HEATING AND AIR COMPANY THAT THE HEATING SYSTEM
REQUIRES REPAIRS THE INVESTOR OWNER/LANDLORD MUST PAY FOR THE REPAIRS. IF THE HEATING
SYSTEM IS DEEMED UNSAFE BY A LICENSED HEATING COMPANY AND NEEDS TO BE REPLACED, THE
INVESTOR OWNER/LANDLORD WILL BE RESPONSIBLE FOR THE REPLACEMENT, REPAIR OR REPLACEMENT
MUST BE COMPLETED BY A LICENSED HEATING COMPANY. NO FURTHER WEATHERIZATION SERVICES
WILL BE PROVIDED UNTIL THE SYSTEM IS REPAIRED OR REPLACED.
IF NO NOTIFICATION OF REPAIR/REPLACEMENT IS RECEIVED BY THIS OFFICE WE WILL NOTIFY THE
BUILDING AND SAFETY DEPARTMENT FOR FOLLOW-UP. THE DEPARTMENT OF SAFETY WILL BE
CONTACTED 60 DAYS AFTER THE RECEIPT OF COMMUNITY ACTION PARTNERSHIP NOTIFICATION TO YOU.
IF INSULATION IS TO BE ADDED TO THE STRUCTURE, AND THE ELECTRICAL SYSTEM IS COMPRISED OF A
FUSE BOX AND KNOB AND TUBE WIRING, LOCAL CODES REQUIRES THAT S-FUSES BE INSTALLED IN THE
FUSE BOX. YOU MAY CHOOSE TO CONSULT WITH AN ELECTRICIAN TO DETERMINE IF A NEW BREAKER BOX
WOULD BE DESIRABLE. S-FUSES WILL BE INSTALLED AT THE TIME OF THE INITIAL INSPECTION. THIS IS A
SAFETY MEASURE AND SHOULD BE VIEWED AS A PERMANENT ADJUSTMENT TO YOUR STRUCTURE.
Signed ________________________________________________ Date _________________________
(Owner/Landlord’s Signature)
Address _______________________________________________ Phone ________________________
(Landlord’s Address)
PARTICIPANT REQUEST
Case No. _______________
I request Weatherization of my home at _____________________________________________________. I give permission to
allow work on my property.
I affirm that my income is within the programmatic guidelines as they have been explained to me. I further affirm that all
documentation I have shown the agency contacting me for this program is legitimate and understand that the making of false
statements is punishable by law. I further agree to assist Community Action Partnership to verify any income source that it
believes needs to be verified.
I authorize Community Action Partnership Weatherization personnel to inspect my home, and perform such Weatherization as
I may be eligible for within the agency’s guidelines. I further authorize this certification for spot checks by Community Action
Partnership staff, Nebraska State Energy Office, or Department of Energy staff, under the State Energy Office’s guidelines and
Department of Energy’s guidelines. The service will be supplied to me at no cost as tenant/owner occupant of the above
referenced structure.
I affirm that I am now living in the residence for which I have applied for Weatherization services. I plan to continue to live at
this address for at least six months, or longer from the date Weatherization is completed.
FURTHER, I AGREE THAT IF I HAVE KNOWINGLY FALSIFIED THE INCOME OR OWNERSHIP OF THE
PROPERTY AT THE ABOVE ADDRESS IN APPLICATION FOR WEATHERIZATION, I WILL MAKE FULL PAYMENT
FOR LABOR AND MATERIALS USED.
I understand that if all eligibility criteria are met I will receive Community Action Partnership Weatherization service. It will
be provided to me free of any lien or debt.
FUEL INFORMATION RELEASE
I certify that I am the owner and/or authorized agent for the property at the address previously given on this form, and I hereby
authorize
________________________________________
Natural Gas Company/Supplier
_______________________________________
Electric Company/Supplier
________________________________________________ to release information on my fuel bills, both past and
Fuel Supplier - Other
future, to the Community Action Partnership and the Nebraska Energy Office.
I understand that all information related to this application is confidential and will be used only to provide data for the above
named agencies, and no information obtained through this release shall be made public in such a manner that the dwelling or
occupants can be identified.
Household Applicant ___________________________________________ Date ________________________
Account Holder/Applicant’s Signature
Signed ______________________________________________________ Date __________________________
Account Holder’s Signature if different than above
RETURN TO: COMMUNITY ACTION PARTNERSHIP, 210 ‘O’ STREET, LINCOLN, NE 68508
COMMUNITY ACTION PARTNERSHIP OPERATES AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION PLAN
Program:
(For Staff Use
ONLY!)
First Name
M
i
d
d
l
e
Social
Security #
Last Name
Phone Number:
Date:
For the purpose of complying with Neb. Rev. Stat. 4-108 through 4-114, I attest as follows:
 I am a citizen of the United States
OR  I am a qualified alien under federal Immigration and Nationality Act, my immigration
status and alien number are as follows:_______________________________________________________, and I agree to provide a
copy of my USCIS documentation upon request.
I hereby attest that my response and the information provided on this form and any related application for public benefits are true,
complete, and accurate and I understand that this information may be used to verify my lawful presence in the United States.
Print Name:___________________________________________________________________
Signature:_____________________________________________________________________ Date:__________
Household Information:
Number Adults:____________
Number Children:___________
Household type (Check one):  Couple with No Children
 Grandparent(s) & Child
 Two Parent Family
 Single Person
*Family Form: Please fill out all sections of this form.
Date of Birth: (mm/dd/yyyy): ________/______/_________
Month
Day
Year
 Single Male Parent
 Couple (Parent & Friend) with Child(ren)
 Single Female Parent
 Foster Parent
 Other
Gender:  Male
 Female
Ethnicity:
 Hispanic/Latino
 Other (Non-Hispanic/Latino)  Refused
Race:
 American Indian or Alaskan Native
 Asian
 Black or African American
 Native Hawaiian or Other Pacific Islander
 White
 Refused
 Multi-Racial(please list)_________________________________________
Marital Status: Single Married Divorced Widowed
Education: For primary adult
Highest Level of Education Attained:
 K-8th Grade
 Some High School
 GED
No School completed
 High School Diploma
 Some College
 College Degree
 Other:_______________
 Some Technical School
 Technical School Certification
 Graduate Degree
 9th Grade
 10th Grade
 11th Grade
 12th Grade, no diploma
Medical Insurance Status:
None (Self Pay)
Medicaid
 Medicare
VA Benefits
General Assistance
Medicare & Medicaid
Private Insurance
Private & Medicaid
 Native American Health
Medicaid Share of Cost
Are you a U.S. military veteran who served in active duty?
 Yes
 No
 Don’t Know
 Refused
Do you have a disabling condition?
 Yes
 No
 Don’t Know
 Refused
If yes what is Disability?____________________________________________, Of long duration?
 Yes
 No
If yes to disability condition, are you currently receiving services or treatment for this condition?
 Yes
 No
Domestic Violence Victim/Survivor?  Yes
 No
*Do you Receive Food Stamps?
 Yes
 No
Income/Household Budgeting:
Income received from any source in the last 30 days?  Yes
 No
Give amounts for all CASH items you are receiving for all members of your household.
$_________A Veteran’s Disability
$_________Pension from former
$_________SSA
Payment
Job
$_________SSDI
$_________AABD
$_________Pension/Retirement
$_________SSI
$_________Alimony or Spousal
$_________Private Disability
$_________Stipend
Support
Insurance
$_________TANF
$_________Child Support
$_________Railroad Retirement
$_________Unemployment
$_________Contributions from Other
$_________Rental Income
$_________Veteran’s Pension
People
$_________Retirement Disability
$_________Worker’s Compensation
$_________Earned Income/Earned
$_________Retirement income
from Job
from Social Security
$_________No Financial Resources
$_________Self Employment Wage
$_________Other
Total Monthly
Income:____________
Non-Cash Benefits: (check all that apply) List amounts when possible!
$_________Food Stamps
SCHIP/Kids Connection
TANF Transportation
$_________Section 8, Public Housing
OTHER TANF Funded Services
WIC
or Rental Assistance
Veteran’s Medical Services
Medicaid
$_________Temporary Rent Assistance
TANF Child Care
Medicare
LIHEAP/Energy Assistance
Court ordered Child Support Eligible?  Yes
 No
If yes, Receiving?  Yes
 No
Are you pregnant?  Yes
 No
If yes Due Date?____________
Are you Homeless?
 Yes
 No
Housing Status? Literally Homeless  Imminently losing housing  Unstably Housed  Stably Housed
 Don’t Know
If Homeless, why?____________________________________________
Where did you Stay Last Night? (select one)
 Emergency Shelter (including Hotel or motel paid w/emergency shelter voucher)
 Permanent housing for formerly homeless persons( such as SHP, S+C, or SRO )
 Transitional housing for homeless
 Rental w/ other non-VASH Subsidy
 Owned by client
Foster care home or group home
 Safe Haven
 Hospital
 Rental by client with VASH Subsidy
 Substance Abuse Treatment
Ctr/Detox Ctr
 Hotel/motel (w/o emergency shelter)
 Place not meant for habitation
 Other
 Jail/Prison/Juvenile Detention Facility
 Psychiatric hospital or facility
 Don’t Know
 Living with Family
 Rental house/apartment
 Refused
 Living with Friends
 Rental w/Out VASH Subsidy
Length of Stay (How long have you been staying in this Type of Living Situation?):
 One week or less (less than 7 days)
 More than one week, but less than one month (8 to 30 days)
 One to three months (30 to 90 days)
 More than three months, but less than one year (90 days but less than 12 months)
 One year or longer (more than 12 months)
 Don’t Know
 Refused
Current Address: Where you are currently living or staying.
Zip Code of Last Permanent
Address:_____________
Address:
City
State
Zip Code
Phone:
Primary reason for seeking assistance:__________________________________________________________________________
Monthly Housing Cost(Rent/Mortgage):____________________
*Monthly Utility Cost(Gas, Electric, Water):___________________
Primary Means of Transportation:  Bicycle  Bus  Car  Friend/family  Taxi  Walk  Other (specify): ___________
Referred to Services by:  Community-based agency
 Faith-based agency
 State Agency  Newspaper  TV
Friends/Family
 Walk-in
 Radio
 Other (specify): ___________
Have you been discharged from one of the following facilities within the last three months? Yes  No
If yes, check all that apply:  Regional Center
 Prison
 Jail  Youth Detention Center  Hospital
Employment:
Currently Employed?
Yes  No
Start Date: ___________
How many hours per week do you work? ______ Are you Fulltime____ or Part-time___ Other (Specify) __________
What is your Hourly wage rate/rate of pay: $_________per hour
Benefits offered through employer? Yes
 No
If yes, are you currently receiving them? Yes
*What level of benefits are offered through your employer? Full Benefits* Partial Benefits**
 No
No Benefits
*Full benefits mean the following are offered: health, vision, dental, 401K/retirement, sick leave, and vacation leave(or PTO)
**Partial benefits must include some health benefits.
If you are not employed, are you looking for work? Yes
 No
Please complete this section for other adult member in your household.
Daughter
Grandfather
Husband
Father
Grandmother
Mother
Granddaughter
Grandson
Significant Other
First Name
Middle Name
Relationship to Primary Adult(choose one):
Son
Wife
Step-Daughter
Other Relative
Step-Son
Other non relative
Last Name
Social Security Number
Gender:  Male
Date of Birth: (mm/dd/yyyy): ________/______/_________
Month
Day
Year
Ethnicity:
 Hispanic/Latino
Race:
 American Indian or Alaskan Native
 White
 Female
 Other (Non-Hispanic/Latino)  Refused
 Asian
 Refused
 Black or African American
 Native Hawaiian or Other Pacific Islander
 Multi-Racial(please list)_________________________________________
Marital Status: Single Married Divorced Widowed
*Education:
Highest Level of Education Attained:
 K-8th Grade
 Some High School
 GED
 No School completed
 High School Diploma
 Some College
 College Degree
 Other:_______________
 Some Technical School
 Technical School Certification
 Graduate Degree
 9th Grade
 10th Grade
 11th Grade
 12th Grade, no diploma
Medical Insurance Status:
No Insurance(Self Pay)
Medicaid
 Medicare
VA Benefits
General Assistance
Medicare & Medicaid
Private Insurance
Private & Medicaid
 Native American Health
Medicaid Share of Cost
Are you a U.S. military veteran who served in active duty?
 Yes
 No
 Don’t Know
 Refused
Do you have a disabling condition?
 Yes
 No
 Don’t Know
 Refused
If yes what is Disability?____________________________________________, Of long duration?
 Yes
 No
If yes to disability condition, are you currently receiving services or treatment for this condition?
 Yes
 No
Domestic Violence Victim/Survivor?  Yes
 Yes
 No
 No
*Do you Receive Food Stamps?
Court ordered Child Support Eligible?  Yes
 No
If yes, Receiving?  Yes
Are you pregnant?  Yes
 No
If yes Due Date?____________
Have you been discharged from one of the following facilities within the last three months? Yes
If yes, check all that apply:  Regional Center
 Prison
 Jail
 No
 No
 Youth Detention Center  Hospital
Employment:
Currently Employed?
Yes  No
Start Date: ___________
How many hours per week do you work? ______ Are you Fulltime____ or Part-time___ Other (Specify) __________
What is your Hourly wage rate/rate of pay: $_________per hour
Benefits offered through employer? Yes
 No
If yes, are you currently receiving them? Yes
*What level of benefits are offered through your employer? Full Benefits* Partial Benefits**
 No
No Benefits
*Full benefits mean the following are offered: health, vision, dental, 401K/retirement, sick leave, and vacation leave(or PTO)
**Partial benefits must include some health benefits.
If you are not employed, are you looking for work? Yes
 No
Complete these sections for each child in your home, if you need additional forms, please ask a staff member.
First Name
Middle Name
Last Name
Social Security Number
Relationship to Primary Adult(choose one): Daughter Son Step-Daughter Step-Son Granddaughter Grandson
Foster Child
Date of Birth: (mm/dd/yyyy): ________/______/_________
Month
Day
Year
Gender:  Male
 Female
Ethnicity:
 Hispanic/Latino
 Other (Non-Hispanic/Latino)  Refused
Race:
 American Indian or Alaskan Native
 Asian
 Black or African American
 Native Hawaiian or Other Pacific Islander
 White
 Refused
 Multi-Racial(please list)_________________________________________
*Education: Select current grade in school
 No School completed
Nursery School-4th
 K-8th Grade
 5-6th Grade
th
th
th
 7-8 Grade
 9 Grade
 10 Grade
 11th Grade
th
 12 Grade, no diploma
 Some High School
 GED
 High School Diploma
 Some College
 Other:____________
Medical Insurance Status:
No Insurance(Self Pay)
Medicaid
 Medicare
VA Benefits
General Assistance
Medicare & Medicaid
Private Insurance
Private & Medicaid
 Native American Health
Medicaid Share of Cost
Do you have a disabling condition?
 Yes
 No
 Don’t Know
 Refused
If yes what is Disability?____________________________________________, Of long duration?
 Yes
 No
If yes to disability condition, are you currently receiving services or treatment for this condition?
 Yes
 No
Court ordered Child Support Eligible?  Yes
 No
If yes, Receiving?  Yes
 No
Complete these sections for each child in your home, if you need additional forms, please ask a staff member.
First Name
Middle Name
Last Name
Social Security Number
Relationship to Primary Adult(choose one): Daughter Son Step-Daughter Step-Son Granddaughter Grandson
Foster Child
Date of Birth: (mm/dd/yyyy): ________/______/_________
Month
Day
Year
Gender:  Male
 Female
Ethnicity:
 Hispanic/Latino
 Other (Non-Hispanic/Latino)  Refused
Race:
 American Indian or Alaskan Native
 Asian
 Black or African American
 Native Hawaiian or Other Pacific Islander
 White
 Refused
 Multi-Racial(please list)_________________________________________
*Education: Select current grade in school
 No School completed
Nursery School-4th
 K-8th Grade
 5-6th Grade
th
th
th
 7-8 Grade
 9 Grade
 10 Grade
 11th Grade
 12th Grade, no diploma
 Some High School
 GED
 High School Diploma
 Some College
 Other:____________
Medical Insurance Status:
No Insurance(Self Pay)
Medicaid
 Medicare
VA Benefits
General Assistance
Medicare & Medicaid
Private Insurance
Private & Medicaid
 Native American Health
Medicaid Share of Cost
Do you have a disabling condition?
 Yes
 No
 Don’t Know
 Refused
If yes what is Disability?____________________________________________, Of long duration?
 Yes
 No
If yes to disability condition, are you currently receiving services or treatment for this condition?
 Yes
 No
Court ordered Child Support Eligible?  Yes
 No
If yes, Receiving?  Yes
 No
Complete these sections for each child in your home, if you need additional forms, please ask a staff member.
First Name
Middle Name
Last Name
Social Security Number
Relationship to Primary Adult(choose one): Daughter Son Step-Daughter Step-Son Granddaughter Grandson
Foster Child
Date of Birth: (mm/dd/yyyy): ________/______/_________
Month
Day
Year
Gender:  Male
 Female
Ethnicity:
 Hispanic/Latino
 Other (Non-Hispanic/Latino)  Refused
Race:
 American Indian or Alaskan Native
 Asian
 Black or African American
 Native Hawaiian or Other Pacific Islander
 White
 Refused
 Multi-Racial(please list)_________________________________________
*Education: Select current grade in school
 No School completed
Nursery School-4th
 K-8th Grade
 5-6th Grade
 7-8th Grade
 9th Grade
 10th Grade
 11th Grade
 12th Grade, no diploma
 Some High School
 GED
 High School Diploma
 Some College
 Other:____________
Medical Insurance Status:
No Insurance(Self Pay)
Medicaid
 Medicare
VA Benefits
General Assistance
Medicare & Medicaid
Private Insurance
Private & Medicaid
 Native American Health
Medicaid Share of Cost
Do you have a disabling condition?
 Yes
 No
 Don’t Know
 Refused
If yes what is Disability?____________________________________________, Of long duration?
 Yes
 No
If yes to disability condition, are you currently receiving services or treatment for this condition?
 Yes
 No
Court ordered Child Support Eligible?  Yes
 No
If yes, Receiving?  Yes
 No
Complete these sections for each child in your home, if you need additional forms, please ask a staff member.
First Name
Middle Name
Last Name
Social Security Number
Relationship to Primary Adult(choose one): Daughter Son Step-Daughter Step-Son Granddaughter Grandson
Foster Child
Date of Birth: (mm/dd/yyyy): ________/______/_________
Month
Day
Year
Gender:  Male
 Female
Ethnicity:
 Hispanic/Latino
 Other (Non-Hispanic/Latino)  Refused
Race:
 American Indian or Alaskan Native
 Asian
 Black or African American
 Native Hawaiian or Other Pacific Islander
 White
 Refused
 Multi-Racial(please list)_________________________________________
*Education: Select current grade in school
 No School completed
Nursery School-4th
 K-8th Grade
 5-6th Grade
 7-8th Grade
 9th Grade
 10th Grade
 11th Grade
 12th Grade, no diploma
 Some High School
 GED
 High School Diploma
 Some College
 Other:____________
Medical Insurance Status:
No Insurance(Self Pay)
Medicaid
 Medicare
VA Benefits
General Assistance
Medicare & Medicaid
Private Insurance
Private & Medicaid
 Native American Health
Medicaid Share of Cost
Do you have a disabling condition?
 Yes
 No
 Don’t Know
 Refused
If yes what is Disability?____________________________________________, Of long duration?
 Yes
 No
If yes to disability condition, are you currently receiving services or treatment for this condition?
 Yes
 No
Court ordered Child Support Eligible?  Yes
 No
If yes, Receiving?  Yes
 No
NMIS Release of Information
I hereby certify that to the best of my knowledge the information contained herein is true, correct and complete and that all the attachments
provided by me, verifying my income, are valid. I understand that this information is utilized to determine eligibility for services for which I am applying. All
the information contained on this document is used only for the purpose in accordance with the Privacy Act of 1974. The Social
Security Number is used to identify and retrieve service records. This agency does not discriminate on the basis of sex, age, religion, race or
national origin.
I understand that my signature authorizes the following:
1.
To determine eligibility for services.
2.
Release of information to services for which I am eligible
3.
Allow information to be entered into the Nebraska Management Information System (NMIS) a statewide database to be
shared with other social service agencies in the state.
I understand that I do not have to participate in the NMIS. I understand that I may revoke this authorization at any time, by doing so in writing to the
NMIS user agency named above. A revocation of this authorization will be effective except to the extent the entity disclosing the information has
taken action relying on this authorization. This authorization will expire 3 Years from the date I sign it. I understand that revocation or expiration of
this authorization will not affect information that has already been entered into the NMIS database in reliance on this authorization.
Applicant Signature: ___________________________________________ Date: ______________________________