2015 COMMUNITY CONNECTIONS PROGRAM APPLICATION
ELIGIBILITY REQUIREMENTS:
Applicant(s) must meet the following income guidelines and reside in Summit County.
Family Size
Total Gross
Annual Household
Income
1
2
3
4
5
6
7
More than 8
$23,540
$31,860
$40,180
$48,500
$56,820
$65,140
$73,460
Add $8,120 per
member
PLEASE COMPLETE AND SIGN ALL SECTIONS OF THE APPLICATION AND PROVIDE COPIES OF THE
FOLLOWING DOCUMENTATION:
Enclosed
N/A
Description of Documentation Required
Proof of Age/Identity (Driver’s license, State I.D. card, or birth certificate)
Child Support: A copy of the CSEA printout for the last twelve (12) months
Alimony: A copy of Court Order
Copy of SSI Award letter or bank statements showing deposits for the last twelve (12) months
Copy of SSDI Award Letter or bank statements showing deposits for the last twelve (12) months
Twelve (12) months of documentation for any other income; W2, 1099, previous year tax return
Copy of the Entire Current Electric Bill
Provide the self-declaration of income notarized letter for individuals 18 years old and older if applicable
Please remember to send copies, not originals, of the above documents to the following address
Akron Urban League
Community Connections Program
440 Vernon Odom Boulevard
Akron, Ohio 44307
Fax: 330-434-2716
For questions and/or additional information call: (234) 542-4149
The mission of the Akron Urban League is to improve the quality of life for the citizens of Summit
County particularly African-Americans through economic self-reliance and social empowerment.
SECTION 1: APPLICANT INFORMATION
Applicant’s First, M.I & Last Name
Date of Birth:
Current Service Address:
Apartment / Lot /Unit / Floor:
City:
County/Municipality/Township:
Applicant’s Social Security Number:
Age:
Zip Code:
Email:
Phone: Home
Work:
Cell:
Are you  Male  Female?
Are you Hispanic?  Yes  No
Ethnicity (Please check only one of the following) Required for Funding purposes.
 Caucasian
 Pacific Islander
 African American
 American Indian/Alaskan Native & Caucasian
 Asian
 American Indian/Alaskan
 American Indian
 Native & African American
 Alaskan Native
 African American & Caucasian
 Native Hawaiian/Other
 Asian & Caucasian
Including yourself, please list the names, relationships, social security number(s), date(s) of birth of everyone
living in your household. Attach proof of disability and citizenship/alien status if applicable.
(Additional household members list on back.)
Household Members
Relationship
Social Security
Number
Income
Source
Date of
Birth
SELF
Pregnant? Disabled?
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Please list your total gross household income for the last 12 months. Include all income of all person(s) living in
household except for wage or salary income earned by dependent minors under the 18 years of age. Please
Attach proof of income. Failure to provide the required income documents will delay the processing of your
application.
Total Gross for last 12 months
Income Source
Yes
No
Child Support


Alimony


Pension


Social Security or SSI


Do you have any other income? 

Current
Last 6 Mo.
Last 12 Mo.
If yes, please attach a separate sheet listing other income.
SECTION 2: ACCOUNT INFORMATION
Are you on PIPP?  Yes  No If yes, please provide a copy of the most recent Electric bill from your current
address with the primary applicants name listed on bill. (Bill must include ALL pages)
Electric Provider
Account #
What is your main source of heat? (Check only one)
 Natural Gas
 Bottle Gas or Propane (L.P. Gas)
 Electric
 Fuel Oil or Kerosene
 Coal, Wood or Pellets
 Other
Do you rent or own your home?  Own/Buying  Rent  Rent/Land Contract
Landlord’s Name/ Organization:
Address:
City:
State / Zip:
Check the box that most closely describes the type of building in which you live (Check only one)
 Mobile Home
 Single Family
 Multi-Family (3 Stories or less
 Multi Family High-Rise (4 Stories or more)
I/We certify under penalty of law that the information contained in this application is true, accurate and complete to the best
of my knowledge.
I/We realize that failure to provide all information requested could result in the application being declined.
I/We understand that there are significant penalties for submitting false information, including the possibility of fines and
imprisonment for knowing violations.
I/We authorize Akron Urban League to secure verification from all available sources necessary to complete the processing
of this application for the purpose of receiving assistance through the Akron Urban League Community Connections
Program.
I/We understand that submitting an application does not mean that I/we will be provided with any assistance from the Akron
Urban League.
I/We understand that funding is limited and only a limited number of homes will be chosen and that my home may not be
chosen even if I/we meet all qualifications.
I/We acknowledge that we have read (or had read to me/us) and do thoroughly understand and by my/our signatures here
below affirm to the above.
***By signing I authorize the Akon Urban League Community Connections Office to contact my electric provider on behalf to
receive my electric account’s monthly and annual usage totals. ***
Applicant’s Name (Printed)
Date
Applicant’s Signature
Date
Privacy Policy
This notice describes the privacy policy of the Akron Urban League (AUL). AUL may amend this policy at any time. AUL
collects personal information only when appropriate. AUL may use or disclose your information to provide you with services.
AUL may also use or disclose it to comply with legal and other obligations specifically if funds used to complete the work on
your behalf are provided through the County of Summit. Your private information (social security number, financial
information, etc.) cannot be publically viewed, sold, or accessed by anyone other than appropriate staff and governmental
funders. In that case, any information provided becomes part of the public record as mandated by applicable laws. AUL
assumes that you agree to allow us to collect information and to use or disclose it as described in this notice. Applicants can
inspect their personal information that we maintain at any time. Applicants can also ask us to correct inaccurate or
incomplete information. Applicants can ask us about our privacy policy or practices. AUL will respond to questions and
complaints.
I/we acknowledge that we have read (or had read to me/us) and do thoroughly understand and by my/our signatures here
below do affirm to the above.
Applicant’s Name (Printed)
Date
Applicant’s Signature
Date
Co-Applicant’s Name (Printed)
Date
Co-Applicant’s Signature
Date
AUTHORIZATION TO RELEASE INFORMATION FORM
If you would like to list ONE other person other than yourself as an approved person for us to speak with regarding your
application, please provide us with the following information:
Contact Name:
Address:
City:
Home Phone:
State:
Zip Code:
Cell Phone:
Email Address:
Relationship to Applicant:
I, (applicant/owner name) give permission to Akron Urban League to provide the above referenced person any information
regarding my application(s) on my behalf.
I understand that if a family member, friend, and/or neighbor contacts Akron Urban League that is NOT the person listed
above, the Akron Urban League will not provide that person with any information regarding my application and will request
the person get written permission from me.
By signing this consent, I am giving Akron Urban League permission to release information to the above referenced person
regarding my application on file with Akron Urban League.
Applicant’s Name (Printed)
Date
Applicant’s Signature
Date
Co-Applicant’s Name (Printed)
Date
Co-Applicant’s Signature
Date
Please note you only have to return this form if you wish to have someone else listed as an additional contact
person on your application.