CARES Act Application

Pandemic Relief Application

Eligibility

Any person with a significant disability who is a resident of Kentucky and who is willing to become a consumer with our agency; or a person with a significant disability that affects your day-to- day life and who is willing to become a consumer with our agency; and

Must meet 200% of the poverty level which was determined by HHS; and

Must be a resident of Kentucky;

Must be able to provide appropriate documentation to show that this is a need as a direct effect of COVID (a letter from an employer that you lost employment, letter from a doctor that you are at high risk or asked to quarantine, you were diagnosed with COVID, there was an interruption in a service due to COVID; and

Must provide documentation of the need for assistance. This can include (but is not limited to) account numbers, past due balance amounts, contact information for the business/individual.

Direct Financial Support that can be requested

Applications will be assessed based on need and documentation of that need. Things that can be requested include financial assistance with rent travel, utilities, food, and PP. Other expenses based on individual needs may be allowed.

All requests must be directly related to the COVID-19 Pandemic. Please be aware that financial assistance payments will go directly to the entity in which the payments are made. No cash will be directly delivered to the consumers.

Application Review

Applications will be reviewed by CAL Leadership Team and will be funded based off the criteria from ACL in regards to the COVID-19 pandemic. The evaluation will be based on need, the documentation of that need, and whether the applicant has demonstrated that the assistance requested will facilitate or support the individual maintaining their independence in the community. In addition, applications will be reviewed to ensure there are no other means for addressing this issue. Referrals will be made to other organizations if the need can be met somewhere else. This is intended as payment of last resort to assist our consumers who have no other means of support during the Covid-19 Pandemic. Staff may ask for verification or documentation of the requested items. Financial eligibility will be assessed.

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* 1. Contact Information

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. County

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* 3. Race (Optional)

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* 4. Date of Birth

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* 5. I attest that the information submitted in this application is true and I understand the Executive Committee review team will confirm this information in order to make a determination about funding this application

Name

Date

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* 6. What is your disability? Briefly explain how it affects your life.

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* 7. Please enter the amount of assistance you currently receive.

Social Security Disability (SSDI)

Supplemental Security Income (SSI)

Unemployment

Workers Compensation

Section 8 Assistance

Medicaid/Medicare

Medicaid Waiver Assistance

Food Stamps (SNAP)

Other

Total

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* 8. If you entered any amount in 'Other' above, please specify the source of those funds.

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* 9. How have you been impacted by COVID-19? Please explain in length?

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* 10. What are you requesting assistance for?

Rent

Utilities

Food

Personal Protection Equipment (PPE)

Transportation

Personal Care Support

Technology

Other (please specify)

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* 11. For each item checked above, please specify the amount in dollars of assistance being requested. Also include the total amount being requested.

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* 12. Explain how the financial assistance or supports will make a difference in your life: Click or tap here to enter text.

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* 13. If you receive financial support, what goals can we assist you with in maintaining your independence in the community during this time?

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* 14. If funded, how will this increase your ability to make choices and decisions during this time?

Please provide supporting documentation to your request by emailing to CALcaresgrant@gmail.com or faxing it to (502) 589-3980. This could include, but is not limited to:

Ø If seeking rental assistance-Letters from landlord.

Ø If seeking technology-Estimates.

Ø If seeking financial assistance with payments- Late payment or cut-off notices.

Ø Please provide verification of income with- copies of your SSDI or SSI award letters or verification of unemployment insurance and food stamp benefits.

Also, please provide documentation that your issues are COVID-related such as:

* A letter from an employer that you were laid off due to COVID.

* a doctors note that you had to quarantine or were positive for COVID.

* a letter from a service provider that you have had a delay in service due to COVID.

* Any other pertinent documentation.