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Home My WebLink Abouthcsa-housing-assistance-fund-application-form-fillableHOUSING ASSISTANCE FUND APPLICATION Due to the sensitive nature of client information, this information shall be used by authorized staff only. Last revised May 2025 SERVICE PROVIDER INFORMATION Name of Referring Service Provider: (First, Middle, Last, Suffix) Name of Referring Service Agency: Name of Referring Service Program: Service Provider Phone Number: Service Provider E-mail Address: Service Provider Address: (Number, Street, City, Zip Code) APPLICANT INFORMATION Name of Applicant: (First, Middle, Last, Suffix) Applicant’s Date of Birth: Applicant’s Phone Number: Applicant’s E-mail Address: Is the applicant currently experiencing homeless or have they exited homelessness within the last 60 days? Yes  No  Is the applicant’s income at or below 40% of the Area Median Income? Yes  No  Is/was the applicant staying in Alameda County when experiencing homelessness? Yes  No  Is the identified permanent housing unit in Alameda County*? Yes  No  * Households are not required to stay in Alameda County to be eligible for this resource. If moving to another county, applications must be approved, and registries submitted within 30 days to maintain eligibility. Additionally, the housing plan section of the application must address plans for any needed supports in the new area. Please use the application checklist found on our webpage and linked here to ensure that all required documents are included when submitting an application. Missing or incomplete documents can lead to delays in processing. HOUSING ASSISTANCE FUND APPLICATION Due to the sensitive nature of client information, this information shall be used by authorized staff only. Last revised May 2025 HOUSING HISTORY Please check TWO total boxes on the chart below. In the “qualifying” column (far left), please check ONE box that reflects the applicant’s living situation that qualifies them to apply for this assistance (either where they are currently experiencing homelessness or where they were staying immediately prior to moving into housing). In the “planned/current” column, please check ONE box that describes the permanent housing situation the household is planning to move into (or has moved into within the last 60 days). for formerly homeless persons hotel/motel paid for with voucher subsidy home subsidy (including RRH) psychiatric medical facility with no homeless criteria room, apartment or house apartment or house facility persons emergency shelter voucher subsidy * A list of definitions for these living situations is available. If you are not sure of the correct response, please contact homestretchfund@acgov.org. HOUSING HISTORY AND HOUSING PLAN INFORMATION The Home Stretch Housing Assistance Fund is meant to be used one time and have a lasting impact. Please briefly describe: 1) the applicant’s qualifying situation, and 2) the applicant’s plan to maintain this housing moving forward. Are there any additional resources or supports that are needed? Please add pages if needed. HOUSING ASSISTANCE FUND APPLICATION Due to the sensitive nature of client information, this information shall be used by authorized staff only. Last revised May 2025 RENTAL/HOUSING INFORMATION Please include a copy of the lease, rental agreement, or intent to rent with the application. What is the size (studio, 1 bedroom etc.) of the applicant’s current/proposed unit? How many people will live there? What is the total rent the client will pay (if subsidized, what is the tenant portion)? What is the total rent for the unit: Is there a rental subsidy (Housing Choice Voucher, VASH, Shelter + Care)? Yes ☐ No ☐ *Note that if there is a rental subsidy, applications must include confirmation of subsidy approval, including identified tenant portion of rent. The next four (4) sections may or may not be required, depending on what kinds of funds are being requested. Complete all relevant sections, then proceed to HAF Request Summary (p5). HOME FURNISHINGS AND HOUSEHOLD ITEMS – IF APPLICABLE What is the estimated total cost of all items requested? $ Address where the items should be delivered (explain if requesting delivery anywhere other than lease address): (Number, Street, Unit Number, City, Zip Code) List any instructions that may be helpful for finding unit at time of delivery: HOUSING UTILITY COSTS – IF APPLICABLE If applying for utility start-up costs, please include a copy of the utility bill with the applicant’s account number. What is the amount owed? Is the applicant required to pay a deposit in order to establish service? If so, how much? What is the total amount requested? In order to increase affordability of utility costs associated with PG&E, please learn more about the CARE or FERA programs. You can visit this link www.pge.com/care or call 1-866-743-2273 for more information. HOUSING ASSISTANCE FUND APPLICATION Due to the sensitive nature of client information, this information shall be used by authorized staff only. Last revised May 2025 UNIT MODIFICATIONS AND MEDICAL EQUIPMENT – IF APPLICABLE Please enclose verification of medical necessity from a medical professional, as well as verification that the applicant attempted to obtain any requested medical equipment through their health insurance. Are you requesting any unit modifications? If so, what modifications are needed? Verification of need must be provided for anything listed in this section. What is the estimated cost of the unit modifications? Has the landlord agreed to the unit modifications? Please include with paperwork. Yes ☐ No ☐ Are you requesting medical equipment? If so, what is needed? Verification of need as well as verification of an attempt to obtain the requested equipment utilizing health insurance must be included. What is the estimated cost of the equipment? Address where the items should be delivered: (Number, Street, City, Zip Code) OTHER ALLOWABLE EXPENSES – MOVING SERVICE – IF APPLICABLE For Other Allowable Expenses (i.e. Moving Service etc.): Please keep in mind that the amount of funding needed must be determined in advance. This means that a moving service with rates based on mileage is not an allowable expense. Please write an explanation of what is needed: What is estimated cost? HOUSING ASSISTANCE FUND APPLICATION Due to the sensitive nature of client information, this information shall be used by authorized staff only. Last revised May 2025 HOUSING ASSISTANCE FUND REQUEST SUMMARY Enter the estimated dollar amount(s) being requested for each expense type. If no funding is requested for a specific line, please write “$0” or leave blank. The grand total should add up to the amount of all funds being requested. Rental Assistance: First Month’s Rent (tenant’s portion only) Amount = $ Security Deposit Amount = $ Total Rental Assistance Requested: Total Amount = $ Household Assistance: Utility Start-Up Costs Amount = $ Estimated Home Furnishings & Household Items Amount = $ Estimated Moving Services Amount = $ Estimated Total Household Assistance Requested: Total Amount = $ Safety and Accessibility: Medically Necessary Items (such as a hospital bed) Amount = $ Unit Modifications Amount = $ Estimated Total Safety and Accessibility Requested: Total Amount = $ Total funds requested in all categories Grand Total= $___________________ HOUSING ASSISTANCE FUND APPLICATION Due to the sensitive nature of client information, this information shall be used by authorized staff only. Last revised May 2025 HOME STRETCH HOUSING ASSISTANCE FUND AGREEMENT I have requested assistance from the Housing Assistance Fund to help me access housing. I understand that I have certain obligations that come with receiving this assistance.  I agree to complete the application with my service provider and to provide accurate and truthful information.  I agree to work with my service provider and others in my support system on my housing plan. I have read, understood and accepted the above agreement and verify my application contains truthful and accurate information. Applicant Signature: Date: Print Name of Applicant: As the service provider working with this applicant, I agree to support the applicant in working on their housing plan and confirm that the information on this form is correct based on the knowledge I have. This includes verifying that the person is currently experiencing homelessness or has exited homelessness in the last 60 days. I attest that I do not have any personal financial interest in the properties or vendors associated with the application. Service Provider Signature: Date: Print Name of Service Provider: ________________________________________________________________________________________ FOR HOME STRETCH PROGRAM USE ONLY – DO NOT WRITE BELOW  Application Approved  Application incomplete  Application Denied (reason in notes) Reviewer’s Signature: Date: Notes: