Housing: Rental and Mortgage Assistance Application

Maui Economic Opportunity, Inc. (MEO) administers multiple housing assistance programs. Each program has its own guidelines and eligibility requirements. Applications will be reviewed and assessed to determine eligibility in the order they are received and assistance is administered based on availability of funding. Priority is based on need.


Current housing assistance programs this application will be considered for include:

  • Rental Assistance Program (RAP)
  • Emergency Food and Shelter Program (EFSP)
  • Maui Fire Relief Housing Program
  • Womens Reintegration Program (WRP)


These programs provide eligible households (Maui County Residents) with necessary assistance to those facing economic hardship to prevent evictions and homelessness throughout the County of Maui. As a requirement to administer these services, applicants must accurately complete this application. Any false or omitted information found may result in denied services.


Target Populations include:

✓Homeless ✓At-risk of Homelessness ✓Moving from emergency or transitional housing✓Reintegrating women ✓Economic Hardship


**Please note that this is not a placement program and does not find housing. Applicants must be physically living in or moving into the home with a secured lease prior to assistance. This program is in very high demand. Applications will not serve as a placeholder if you do not have all of the required documents within the timeframe requested, your application will not be processed and you will have to apply again. Please refrain from applying until you have all of your documents ready for review. You can view the list of required documents at the bottom of the application if you would like to review before applying.

English is my primary language
Do you need an interpreter?
I need an interpreter for the following language:
Requested Assistance
Prefered method of contact.
Applicant Gender

The following responses are not mandatory however, additional funding may exist to support those who identify with the demographics below.

Do you have a Disability ?
What island do you live on?
Type of Health Insurance
Highest education level completed
Do you receive HUD?
Public Assistance
How long have you lived on Maui?
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Ethnicity:
Household Demographics
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Have You Received Rental Assistance previously?

In the last 12 months from today's date

If so, from what Agency?
Do you have a current lease agreement?

Emergency Assistance

Please select YES if ANY of the following apply to you.


  • I have recently received an eviction notice.
  • I recently secured a lease and need assistance with security deposit to move into the new residence.

This program is in very high demand and assistance is processed in the order it is received and prioritized by need, and the availability of funds. If your application is determined to be inactive, you may apply again however your application will be reviewed in the order of submission. Your previous application will not serve as a placeholder. I (applicant), by checking the box below, understand that this application will be reviewed and additional information may be needed to determine program eligibility. I understand what documents are required of me to apply for the rental program and I must be forthright and truthful with all information provided to include but not limited to, disclosing assistance received by any one of the following agencies within the past year; Ka Hale A Ke Ola, Women Helping Women and Family Life Center, Catholic Charities Hawaii.

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Program Agreement, Rights & Grievance Process


I agree to receive housing assistance and case management services from MEO, INC. I understand that I will receive case management services and that I will work with my Case Manager in developing a residential service plan.


I understand that I may be offered financial assistance only as determined by MEO, INC.


I will accept telephone calls and visits from my Case Manager/Housing Specialist.


I will provide accurate information about my income and assets and about where I was living before I accept services from MEO, INC. I will inform my Case Manager if I leave the housing unit. I know that the Housing Specialist or Case Manager will be checking with me to see how I am doing and if I require support.


I understand that I have the following rights:


To RECEIVE CONSIDERATE AND RESPECTFUL CARE AND SERVICES from all staff at all times and under all circumstances, with recognition of dignity and individuality, including privacy in services and care.

RECEIVE TIMELY IMPARTIAL ACCESS TO SERVICES and to be ASSURED OF PRIVACY AND CONFIDENTIALITY of all communications and records pertaining to my care. My legally designated representative or me have ACCESS TO THE INFORMATION contained in my records according to law.


VOICE my grievances without restraints, interference, coercion, discrimination or reprisal, when not satisfied with the resolution to APPEAL MY COMPLAINT OR GRIEVANCE.

FREEDOM FROM abuse, exploitation, retaliation, humiliation and neglect.

RECOGNITION of my culture, race, ethnicity, age, gender, disability, education, sexual orientation, spiritual beliefs, socioeconomic status and language in the services and programs that I receive.


I understand that I may file a written grievance with MEO’s Chief Operating Officer (COO). I will explain, in writing, what has happened. The COO will respond to me, in writing, within five (5) working days. If I remain unsatisfied, I may file a grievance with the Chief Executive Officer (CEO) of MEO, INC. The CEO will respond to my complaint or grievance within ten (10) working days. The response of the CEO is the final step in the grievance process.

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Notice Of Privacy Practices Acknowledgement*

NOTICE OF PRIVACY PRACTICES

March 26, 2017                

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Uses and Disclosures of Health Information

We may use health information about you for treatment (such as sending your medical record information to a specialist physician as part of a referral), to obtain payment for treatment (such as sending billing information to a health insurance plan), for administrative purposes, and to evaluate the quality of care that you receive (such as comparing client data to improve treatment methods).


We may use or disclose identifiable health information about you without your authorization for several other reasons. Subject to certain requirements, we may give out health information without your authorization for public health purposes, abuse or neglect reporting, auditing purposes, research studies, funeral arrangements and organ donation, workers' compensation purposes, and emergencies. We provide information when otherwise required by law, such as for law enforcement in specific circumstances. We may also contact you about appointment reminders or treatment alternatives. In any other situation, we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization to stop any future uses and disclosures.


We may change our policies at any time. Before we make a significant change in our policies, we will change our notice and post the new notice in the lobby of each office, and on our Web site. You can also request a copy of our notice at any time. For more information about our privacy practices, contact the person listed below.


Individual Rights

    

In most cases, you have the right to look at or get a copy of health information about you that we use to make decisions about you. If you request copies, we may charge you a small fee for each page. You also have the right to receive a list of instances where we have disclosed health information about you for reasons other than treatment, payment, or related administrative purposes. If you believe that information in your record is incorrect or if important information is missing, you have the right to request that we correct the existing information or add the missing information.


You have the right to request that your health information be communicated to you in a confidential manner such as sending mail to an address other than your home. If this notice was sent to you electronically, you may obtain a paper copy of the notice.


You may request in writing that we not use or disclose your information for treatment, payment, or administrative purposes or to persons involved in your care except when specifically authorized by you, when required by law, or in emergency circumstances. We will consider your request but are not legally required to accept it.


Complaints

If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact the person listed below. You may also send a written complaint to the U.S. Department of Health and Human Services. The person listed below can provide you with the appropriate address upon request. Under no circumstance will you be retaliated against for filing a complaint.

Our Legal Duty

We are required by law to protect the privacy of your information, provide this notice about our information practices, and follow the information practices that are described in this notice.

If you have any questions or complaints, please contact:


Debbie Cabebe, SHRM-SCP, SPHR, NCRT

Chief Executive Officer

PO Box 2122

Kahului, HI 96733

808-249-2990 extension 300

Debbie.cabebe@meoinc.org

** By checking this box, I am verifying that I have read and understand MEO's Privacy Practices***

CONSENT TO RELEASE PHOTO INFORMATION


I, hereby grant permission to the Maui Economic Opportunity, Inc. to use photographs and/or videos taken of me to be used for the purposes of; publications, news release, online and in other communication.

I release MEO from any and all liabilities involving photographs, videos and information released.

I waive proprietary rights behalf to any or all reproduction of the productions.

I waive proprietary rights to any distribution of the materials.

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EEO View*

WE BELIEVE IN EQUAL OPPORTUNITY

EQUAL OPPORTUNITY IS THE LAW

March 26, 2017

It is against the law for Maui Economic Opportunity, Inc. as a recipient of federal financial assistance to discriminate on the following basis:


Against any individual in the United States, on the basis of race, color, religion, sex or national origin, age, disability, political affiliation or belief; and


Against any beneficiary of programs financially assisted under Title I of the Workforce Investment Act of 1988 (WIA), on the basis of the beneficiary’s citizenship/status as a lawfully admitted immigrant authorized to work in the United States, or his or her participation in any WIA Title I-financially assisted program or activity.


The recipient must not discriminate in any of the following areas:


Deciding who will be admitted, or have access, to any WIA Title I-financially assisted program or activity;


Providing opportunities in, or treating any person with regards to, such a program or activity, or


Making employment decisions in the administration of, or in connection with, such a program or activity.


Furthermore, under state statues, it is against the law for any recipient to discriminate against an individual or on the basis of National Guard participation, ancestry, marital status, arrest/court record, breastfeeding, and sexual orientation.


WHAT TO DO IF YOU BELIEVE YOU HAVE EXPERIENCED DISCRIMINATION


If you think that you have been subjected to discrimination under a WIA Title I-financially assisted program or activity, you may file a complaint within 180 days from the date of the alleged violation with one of the following:


Gary Noda, Equal Opportunity Officer

State of Hawaii, Department of Labor & Industrial Relations

830 Punchbowl ST

Honolulu, HI 96813

PH: 808-586-8867; or


The Director, Civil Rights Center (CRC)

    U.S. Department of Labor,

    200 Constitution Avenue NW, Room N-4123

    Washington, DC 20210


If you file your complaint with the State or County, you must wait either until the recipient issues a written Notice of Final Action, or until 90 days have passed (whichever is sooner), before filing with the Civil Rights Center (see address above.)


If the recipient does not give you a written Notice of Final Action within 90 days of the day on which you filed your complaint, you do not have to wait for the recipient to issue that Notice before filing a complaint with CRC. However, you must file your CRC complaint within 30 days of the 90-day deadline (in other words, within 120 days after the day on which you filed your complaint with the recipient).




If the recipient does give you a written Notice of Final Action on your complaint, but you are dissatisfied with the decision or resolution, you may file a complaint with CRC. You must file your CRC complaint within 30 days of the date on which you receive the Notice of Final Action.


Should you have any questions contact MEO’s Equal Opportunity Officer:


Debbie Cabebe, SHRM-SCP, SPHR, NCRT

Chief Executive Officer

Maui Economic Opportunity, Inc.

PO Box 2122

Kahului, HI 96733

808-249-2990 extension 300

Debbie.cabebe@meoinc.org


*** By checking this box, I am verifying that I a have read and understand MEO's EEO policy. ***

Voluntary Affirmation Action Data View

Check all that apply


PLEASE NOTE: COMPLETION OF THE Voluntary Affirmation is voluntary.


We consider all applicants for programs without regard to race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve/nation guard, or any other similarly protected status. We also comply with all applicable laws governing employment practices and do not discriminate on the basis of any unlawful criteria. In an effort to comply with requirements regarding government record keeping, reporting and other legal obligations which may apply, we request that you complete this applicant data survey. Providing this information is strictly voluntary. Failure to provide it will not subject you to any adverse personnel decision or action. Your cooperation is appreciated.

Please share any other information that will help the case managers with processing your application.

By checking this box, I am verifying that all of the information provided is accurate and true to the best of my knowledge.

Please upload the following documents to expedite your application.


Identification:

  • Photo Identification (Driver’s License, State ID, or Passport) of all household members 18 years+
  • Social Security Numbers and Birth Dates of all household members
  • Birth Certificate for all household members 5 years and younger


Income Verification:

  • Most current pay stubs covering the 30 days before the date of application
  • Social Security Statement of Benefit/Pension
  • Unemployment Benefit Statement
  • Monthly/quarterly financial statement; and G.E.T. if self-employed
  • DHS Notice of Approval for Financial/FS Benefits
  • Supplemental Social Security Income
  • Income Tax Returns
  • Receipts showing how tax refunds were spent
  • Income Tax Extension Letter
  • Other (Child support, Alimony, etc.)



Asset Verification:

  • Current Checking Account Statement
  • Current Savings Account Statement
  • Other (Stocks, bonds, cash on hand, etc.)


Lease Verification:

  • Copy of signed lease (Minimum 6 months) or Unexecuted/Unsigned lease (Minimum 6 months from date of application) may be submitted if not currently living in the rental unit at the time of your rental application. However, the check will not be released until the submittal of the signed lease.
  • Final Notice of Disconnection (Electricity assistance only)
  • Utility Deposit Statement/Print Out from Utility Company
  • Landlord’s General Excise Tax Number (G.E.T.)
  • Tax Map Key (T.M.K.) Numbers Form
  • W-9 Form with Landlord/Property Managers Signature


Eviction Verification:

  • Eviction Letter addressed to the applicant
  • Letter from Public Housing, Homeless or transitional shelter addressed to the applicant
  • The eviction letter must include the following:
  • Date of Eviction Letter
  • Date applicant must vacate the premises
  • Breakdown of costs and the total amount owing
  • Printed name and Signature of evicting landlord
  • The contact number of evicting landlord


Other:

  • Letter explaining why assistance is needed
  • Current Credit Report (www.annualcreditreport.com)
  • Receipt of Payment of Back Rent
  • Rental Subsidy Letter (HUD or DHS) – HUD Contract
  • Rental Subsidy Letter (HUD of DHS) – HUD Notice of Rent Adjustment
  • Home Inspection from HUD (front page of House Inspection form indicating box, passed)
  • Payment arrangement (with dates of scheduled payments) signed and dated by both applicant and landlord for payment of back rent
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