City of College Park

College Park GA CARES Utility Assistance Application

The information provided shall be kept confidential and used only for the purpose of determining eligibility for financial assistance.

Applicant Name:

Current Address:

City/State/Zip:*County: Home Phone:

Email: 

* - Field is mandatory

I rent my home (check one) I own my home (check one)

Yes No Yes No

Housing Type (check one)

Apartment Duplex Mobile Home Condo Single-Family

Home:

Is this your primary residence?

Yes No

HOUSEHOLD COMPOSITION

List the head of household and all other members living in the unit. Give the status of each household member. (wife, son, daughter, dependent, etc.)

Race of head of household (check one):

White Black Asian/Pacific Islander Native American/Alaskan Native Hispanic

American/Alaskan Native Hispanic

INCOME DATA

Enter all regular gross (before taxes or other deductions such as medical insurance) monthly income, for every person living in the house, in the appropriate columns below.

Income includes: Wages, Social Security, Disability, Social Security Income, Pensions, Veterans Administration benefits, Worker's Compensation, Georgia Division of Family and Children's

Service Temporary Aid to Needy Families (TANF) funds, Child Support, Alimony, Unemployment, Self-employment, and any other regular payment received by the household.

Anticipated Income (Monthly)

1.Total Monthly Anticipated Income (add a, b, c, and d and enter the result in e)

2.Total Annual Anticipated Income (multiply e by 12 and enter the result in f)

Savings, Investments, Assets:

Enter all liquid assets such as checking, savings, and cash on hand and on pre-paid benefit cards for all household members.

HARDSHIP

Describe briefly why you fell behind on your housing or utility payments? (i.e., COVID-19 related unemployment, medical costs, childcare issues):

UTILITY PAYMENT

I am seeking Utility assistance for the following: (Please check all that apply)

COVID-19 CERTIFICATION

Please provide a brief description of how your household income was impacted by the COVID-19 pandemic.

APPLICANT AGREEMENT

Penalty for False or Fraudulent Statements:

U.S. C. Title 18, Sec. 1001, provides: “Whoever, in any matter, within the jurisdiction of any department or agency of the United States knowingly falsifies ... or makes or uses any false writing or document knowing the same to contain any false, fictitious or fraudulent statements or entry, shall be fined not more than $10,000 or imprisoned not more than five years, or both.”

Data Privacy Act:

The information being collected is considered private and will not be available to the public. This information will be used only to determine eligibility for the CDBG-CV Utility Relief Grant Program for Citizens. Failure to provide the requested information may jeopardize the application for utility assistance.

1. I/We understand that verification of the information provided above may be obtained from any source.

2. I/We understand, if I/We provide false information or fail to disclose full information as to any material fact/s, that this application may be rejected, may be terminated, and that I/We may be liable in a civil action or other legal remedies at the option of the City of College Park/Fulton County.

3. I/We fully understand that it is a federal crime if I/We knowingly make any false statements for the purpose of obtaining this financial assistance and that it is punishable by fine or imprisonment, or both.

4. I/We certify that all information in this application is true and complete to the best of my/our knowledge and belief.

5. I/We certify that I/We occupy the address above.

6. I/We understand that the funds will be awarded as a grant.

7. I/We certify that we will not receive duplication of benefits from another agency.

8. I/We understand that we may only receive this funding once.

9. I/We understand that we may be required to speak with a HUD-certified Housing Counselor regarding our situation.

Application Certification

College Park Community & Home Improvement and its representatives to assist me with my housing issues including contant with my utility companies. You are authorized to [rpvide any records and information about me and my case including confidential information that may be asked for. 

I/we understand that the above information is being collected to determine if I/we are eligible to receive emergency rental assistance. I/we authorize College Park to verify all information provided on this application.

Head of Household - *Name Date:

*Spouse Date:

By entering your name as head of household or spouse, you are officially signing this document and certifying the information submitted.