This application is designed to assess your eligibility for assistance, but it does not guarantee aid. Assistance is subject to the availability of funds and is not provided immediately. Applications are prioritized based on the urgency of the need.

Please complete each question in the form below. Incomplete applications without requested documentation will be denied. A processor will contact you to get more information and documentation. If you cannot be contacted after 3 attempts, your application will be denied and you will have to reapply.

This application is intended for assistance with past due rent or mortgage payments, relocation outside of the county (with an approved unit), and/or move-in costs within Lee County (with an approved unit). Please note, this is NOT an application for Rapid Rehousing or housing location services.

Program Eligibility Requirements:

• You must have been residing in Lee County for at least the last 90 days
• You must be residing in or approved for a housing unit
• You must have unmet housing needs as a direct result of Hurricane Ian.
• You must have sufficient income to sustain your housing after receiving assistance

FRAUD STATEMENT: The information contained within this form is true, accurate and complete. I understand that priority in assistance will be given to those households with the lowest income and greatest need, i.e., those households in which the elderly, disabled, medically needy or children reside. If approved, I authorize the agency to make benefit payments on my behalf to an eligible vendor account.

I certify that all information entered by me in this form, as well as any attachments or supplemental information provided, are true and accurate to the best of my knowledge.

By providing my signature or typed name below, I acknowledge and confirm that a typed name constitutes a legally-binding signature.

This declaration serves as proof of my residency in Lee County at the time Hurricane Ian made landfall on September 28, 2022. It may qualify me for state or federal assistance provided by Lee County Human and Veteran Services.

I declare that the following statement is true and correct:

• I was a resident in Lee County, Florida on September 28, 2022.

TO WHOM IT MAY CONCERN: I hereby authorize my case manager with Lee County Human and Veteran Services to obtain any information regarding me and I acknowledge such authorization as follows:

1. EXTENT OF AUTHORIZATION This authorization and release shall apply to myself, or to the person whose name appears above, any child of mine, or for any person for whom I am responsible for their care, custody and control. All provisions of this authorization shall apply to such persons.
2. NATURE OF INFORMATION I hereby authorize any person to provide my Case Manager at Lee County Human and Veteran Services all information requested by them, including but not limited to past or present employment records, VA benefits, rental history, medical records, and school records (which shall be deemed to include personnel files, teacher evaluations, intelligence or psychological testing, school medical information or other confidential information).
3. DURATION This authorization shall remain in effect for a period of 1 year, or until my written revocation, whichever occurs first.
4. COPY IN LIEU OF ORIGINAL A copy of this signed original authorization shall have the same force and effect as the original.
5. REASON FOR RELEASE

• Eligibility Determination

I understand that my records are protected from disclosure under Federal and/or state law. I understand that I have a right to revoke the authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the same department/agency receiving the authorization form. I understand that the revocation will not apply to information that has already been released in response to this authorization. Unless otherwise revoked, this authorization will expire one year from the date of signing.

The following disclosure is being made pursuant to section 119.071(5), Florida Statutes.

Social security numbers of applicants and household members are requested because this information has been determined to be imperative for the performance of the duties and responsibilities prescribed by law under the Community Services Block Grant Program. This information is not required by state or federal law; however, social security numbers are necessary to determine eligibility for program services and specifically for the following purposes:

1. To verify an applicant’s identity.
2. To verify household size.

A social security number collected pursuant to this notice can only be used by the Florida Department of Economic Opportunity and Lee County Department of Human & Veteran Services (sub-grantee) for the purposes specified above.

Nondisclosure except under limited circumstances

Social security numbers will not be disclosed to others unless required or authorized by Florida law. Section 119.071(5), Florida Statutes, allows disclosure of a person’s social security number under the following specific, limited circumstances:

• If disclosure is expressly required by federal or Florida law or is necessary for the agency or governmental entity to perform its duties and responsibilities;
• If the individual expressly consents to disclosure in writing;
• If disclosure is made to prevent and combat terrorism pursuant to the U.S. Patriot Act of 2001 or Presidential Executive Order 13224 (blocking property and prohibiting business transactions with persons who commit, threaten to commit, or support terrorism);
• For an agency employee and dependents, if disclosure is necessary to administer the person’s health benefits or pension plan funds; or
• If disclosure is for the purpose of the administration of the Uniform Commercial Code by the office of the Secretary of State.
• If disclosure is requested by a commercial entity for permissible uses under the federal Driver’s Privacy Protection Act of 1994, the federal Fair Credit Reporting Act, or the federal Financial Services Modernization Act of 1999 (for example, to verify the accuracy of personal information provided by the individual to the commercial entity; use by an insurer in connection with claims investigation or anti-fraud activities; for use in connection with a credit transaction).

Acknowledgment of Receipt of Notice

I confirm that I have been provided a copy of this Notice regarding the collection of my social security number and the social security numbers of all household occupants as part of the application process for the Community Services Block Grant Program.