SALVATION ARMY OF ORANGE COUNTY, THE

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