Maui Relief TANF Program

Maui Relief TANF Program - NEW

The Maui Relief TANF Program “Program” provides benefits to eligible families with dependent children with household incomes at or below 350% of the federal poverty level* who either experienced property damage or loss, or lost earnings or employment as a direct result of the wildfire disaster. Additional private funding has been secured to expand these benefits to individuals and families without dependents. The Program benefits are not intended to meet a family’s recurring needs and will not extend beyond four (4) months.

Please allow yourself at least 1 HOUR to complete this application as you will not be able to save your responses and complete at a later time. Please make sure you have ALL of your documents downloaded to your device prior to starting this application as your application will not be processed for eligibility until all necessary documents have been provided, and you will not be able to submit without uploaded documents.

Please note you may be able to submit your application in person at any of the MEO offices located on the islands of Maui, Molokai, and Lanai as well as any of MEO's partnering agencies- Honolulu Community Action Program (HCAP), Hawaii County Economic Council (HCEOC), and Kauai Economic Opportunity (KEO)on the neighboring islands.

*** Upon review of your application more documents may be requested to determine eligibility and process your application***

If your family unit needs help with one or more of the following expenses and has been determined ineligible for or has exhausted disaster relief assistance from other organizations such as the Federal Emergency Management Agency or FEMA, the American Red Cross, or other public or private agencies, please complete the attached application form.

NOTE: If your family unit has not received an eligibility determination from other organizations such as FEMA, the American Red Cross, or other public or private agencies, then consult with an NRST worker before filling out this application.

1. One-time deposit to secure long-term housing (your family unit has a signed lease/rental agreement for 12 months or more)

2. Long-term housing payments up to 4 months (your family unit has a lease/rental agreement or is paying a mortgage)

3. Short-term housing payments up to 4 months (your family unit has a lease/rental agreement for less

than 12 months or is temporarily staying at a hotel, vacation rental, etc.)

4. One-time downpayment to purchase a personal automobile (your family unit has signed a lease or auto loan agreement)

5. Automobile payments up to 4 months (your family unit has a lease/auto loan agreement)

6. One-time utility deposit to connect utility sources (your family unit established accounts with utility companies)

7. Utility payments up to 4 months (your family has accounts with utility companies)

8. One-time clothing allowance for children (between ages 0 and 17 years)

9. One-time clothing allowance for adults (including children between ages 18 and 24 years)

10. One-time allowance for school supplies (school-aged children and adult children up to 24 years old attending college or vocational/trade school)

11. One-time replacement of a refrigerator unit, actual cost up to $1,000

12. One-time replacement of a range unit, actual cost up to $1,000

13. One-time replacement of a washing machine unit, dryer unit, or both, actual cost up to $1,000 or up to $1,750 for replacement of washer and dryer

14. One-time replacement of a microwave or toaster oven, or both, actual cost up to $200.

Please provide proof of the above expenses as well as the following:

Identity for you and your family members
You and your family members are residents of Hawaii
How your family unit was directly impacted by the wildfire disaster (your family lived or worked in one of the affected areas)
Your family unit’s total gross income (includes unearned income such as Social Security or SSI benefits,
pension/retirement, worker’s compensation, unemployment insurance benefits, etc. and earnings from employment or self-employment)
Application for other disaster relief assistance from FEMA, American Red Cross, or other public or privat agencies
Letter of denial for other disaster relief assistance from FEMA, American Red Cross, or other public/private agencies

Note: Information on immigration status is only requested to determine the source of funds to which the benefits will be paid.

Application Date*

Document List*

Please check below once you have reviewed the required documents.

Identification

Drivers License

State ID

Other

Proof of Residency (State of Hawaii)

Utility Bill

Lease

Other

Proof of loss or damage or reduction in earnings or employment loss as the Direct Result of the wildfires.

Union Letter, email, or text

Employer's letter or email

Self- Attestation

Proof of Income

Paystubs

Tax Forms

Unemployment Insurance

Self- Attestation

Proof of a dependent child in the home (For families seeking benefits for dependents)

Lease

Birth Certificate for child reflecting relationship to adult

Tax document

School document

Other

Assistance Request Documents (These items are specific to the assistance you are requesting. Only documents in conjunction with your request need to be provided.)

Utility Bill

Lease

Mortgage Statement

Car Loan Statement

W-9s for Landlord

Are your documents ready uploaded on your device and ready to be uploaded?*

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Please apply again.*

Unfortunately, you have indicated that you do not have all of your documents uploaded at this time. Please exit this application and apply again once all documents are ready to be uploaded with your application. Or visit one of the in-person sites to submit an application in-person. Mahalo!

Last, First Name*

Contact Number*

Phone

Email*

Residential Address*

current and previous address (if loss or damaged)

Zip Code

Address (Mailing)

Mailing City

Mailing Zip Code

What document will you provide to verify your identity?*

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Sex

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Date of Birth

Ethicity

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Race

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Social Security documentation*

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Proof Of Residency

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Citizenship status/ Immigration status

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Proof of direct impact from wildfires*

How was your home or job DIRECTLY impacted by the recent wildfires? Please provide documentation to verify loss or damage to your home or employment.

Loss of hours due to business slowdown is not considered a DIRECT impact under the guidelines of the program.

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Dependent Children Documentation

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Requested Assistance*

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Documentation for other adults*

Please check the document(s) you will be providing to verify adult identity and household relationship

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FEMA ID# (If Applicable)

Prior Living Situation- Homeless

Transitional Housing (TH)

Living situation: past 3 years

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# of Months in current situation

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Family Income & Benefits

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Duplication of Benefits*

Have you or anyone in your family unit applied for any other types of federal, state, local or private disaster relief assistance?

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Approved Benefit*

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Denied Benefit*

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Benefit Pending notice of approval or denial*

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Benefit Program-Denied*

List the program(s) you applied for and was DENIED

Benefit Program - Pending Approval/Denial

List the program(s) you applied for and are waiting for notice of approval or denial

Benefit Program- Approved*

List the program(s) you applied for and have received assistance.

Additional Assistance*

Do you or anyone in your family unit anticipate applying for additional assistance in the next six (6) months?

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Add Family Members*

Please include all of your family members' information in this application. Including the applicant. How many family members will be included?

Household member 1 *

Last, First Name

HM1 DOB*

Household Member 1 Date of Birth

HM1 Citizenship/Immigration Status

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Household Member 1 Relation*

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HM2

Last, First Name

HM2 Relation

How is this person related?

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HM2 DOB

Household Member 2 Date of Birth

HM2 Citizenship/Immigration Status

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HM3

Last, First Name

HM3 DOB

Date of Birth

HM3 Relation

How is this person related?

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HM4

Last, First Name

HM3 Citizenship/Immigration Status

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HM5 Relation

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HM5 Citizenship/Immigration Status

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HM4 Citizenship/Imigration Status

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HM4 DOB

Date of Birth for household member

HM4 Relation

How are you related?

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HM5

Last, First Name

HM5 DOB*

Date of Birth

HM6

Last, First Name

HM6 DOB*

Date of Birth

HM6 Citizenship/Immigration Status

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HM6 Relation*

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HM7 *

Last, First Name

HM7 DOB*

Date of Birth

HM7 Relation

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HM7 Status

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HM8*

Last, First Name

HM8 Relation

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HM8 DOB*

Date of Birth

HM8 Status

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HM9 Name*

Last, First Name

HM9 DOB*

Date of Birth

HM9 Status*

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HM9 Relation*

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HM10 Last, First Name*

HM10 DOB*

Date of Birth

HM10 Relation*

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HM10 Status

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10+ Family Members*

Please list all family additional family members names from eldest to youngest whose information has not previously been entered along with their relationship to the applicant and age. (Example: John Doe- Son 12, Jane Doe- Daughter 21, Sam Smith- Grandson 2, etc.)

File Upload

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Family Rights and Responsibilities

If you do not agree with the eligibility determination or granted NRST benefit amount, you may request a departmental review. Your written request must be submitted no later than thirty (30) calendar days from the date of this notice. Your written request must state that you want a departmental review, an explanation of why you disagree with the determination or benefit amount, and any arguments and evidence that you deem are relevant to support the disputed determination or benefit amount. The departmental review will be conducted by the Department of Human Services (DHS) via telephone, video conferencing, in writing, or by a combination of these methods. DHS may request additional information or verification that may be pertinent to its review. DHS will complete the review and render a decision in writing within fourteen (14) calendar days from the date DHS acknowledged the receipt of your written request for a departmental review.

You and your family have the responsibility to report, within ten (10) calendar days, any changes to your family unit’s circumstances that may affect your family unit’s eligibility for NRST benefits such as, but not limited to, receipt of other emergency or disaster relief assistance that duplicates the NRST benefits; your family unit is no longer residing in Hawaii; or your family unit is no longer in need of the NRST benefits. Your family may be subject to recovery of any overpaid NRST benefits and referral to the DHS Investigations Office for fraud investigation pursuant to section 17-803-9, HAR.

Applicant Certification, Authorization and Understanding

I certify, under penalty of perjury, that my family and I were directly affected by the wildfire disaster and experienced property loss

or damage, reduction in earnings, or employment loss. I also certify the information provided on this application and to DHS and

Department’s Designee are correct and complete to the best of my knowledge.

I understand I will need to cooperate and provide information and supporting documents so DHS or the Department’s Designee will

be able to determine whether me and my family unit are eligible to receive the help I requested on this application. I authorize DHS

and the Department’s Designee to verify my and my family’s information with FEMA, the American Red Cross, utility companies,

financial institutions, or other sources.

I understand, the information on this application form, any subsequent information I may provide, and the outcome of my

application, will be provided to DHS for audit and reporting purposes or if I request for a departmental review. I also understand, if I

willfully withhold or misrepresent my family’s circumstances, or any information on this application and any other documents I

provide, to qualify for and receive benefits, a referral will be made to the DHS Investigations Office for fraud investigation. I further

understand that fraud is punishable under applicable state and federal laws, and repayment to the State is required for any benefits

that my family was not entitled to receive.

Signature*

-Must be signed to be considered an application

Entered by*

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Individual Name, Agency and Email

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