FINANCIAL ASSISTANCE POLICY Subject: Emergency Assistance Program Date: December 8, 2009 Page 1 of 3 PURPOSE: To set minimum eligibility criteria and standardize the process for distribution of Emergency Fund dollars and Ryan White Part A Discretionary Funds to HIV+ clients participating in the AIDS Foundation of Chicago case management system. POLICY: The AIDS Foundation of Chicago receives funding through the Emergency Fund and Ryan White Part A that provides Assistances to assist low income residents in the metropolitan Chicago area including Cook, DuPage, Kane, Lake, McHenry and Will counties. The Emergency Fund is a nonprofit organization which, alone and in partnership with other organizations, provides immediate financial assistance to help low income individuals and families who are below 50% of AMI that are in an emergency situation that cannot be resolved by any other agency or means. Payments can be up to $250.00 and can only be used once per 12 month period. It is at the discretion of AFC staff along with the guidelines established by the funding stream to determine which funding source will be used to provide assistance PROCEDURE: Eligible Expenditures: Expenditures must remove the threat of crisis in a cost-efficient manner. Applications will be reviewed and priority given to applications in the order below: 1. Special items needed for a medical condition but not covered by any medical plan, such as humidifiers, bath chairs, handrails, air conditioners, syringes, orthopedic shoes, medical alert necklaces, lubricants and bandages 2. Important documentation, such as ID s, birth certificates and testing fees 3. Special clothing items for work or school, such as uniforms, coats and steel-toe boots 4. CTA / RTA passes to school, work, medical appointments & public aid appointments 5. Child care and child items 6. Home items, such as beds, refrigerators, blankets and linens for fire and flood victims or relocating families 7. Gift cards for special dietary items not found at food pantries & personal hygiene items 8. Eye glasses and eye exams required for work or school 9. Phone bills when a medical condition requires phone service to the home 10. Medications prescribed by a physician ONLY when the client is not able to obtain assistance through ADAP or directly with the drug company. 11. Special items for families affected by violence and/or abuse, such as replacement locks, bus tickets out of state and child items 12. Other expenditures that prevent or avert crisis, as approved by Emergency Assistance staff before they are made
Examples of ineligible expenditures include, but are not limited to, payments for the following: Rent Mortgage Utilities Motel or hotel stays Hospital bills Home items that are not critical to the household, such as replacements for old but usable furniture, paint, couches and unnecessary appliances Moving trucks and services provided by friends or businesses that require credit card deposits, mileage fees and add-ons for vehicle damage Cooking gas, unless client receives a housing subsidy and faces eviction for impending disconnection Travel expenses and special clothing for funerals, graduations or other special occasions Partial payments for chronic rental or utility issues that might buy time for the client, but doesn t really resolve the issue Pet food, vet visits or other items related to pet care Morphine or other medications that have not been prescribed by a physician Fees for marriage certificates, divorces, parking tickets, fines, bail and court-ordered drug or psychological evaluations Services already provided to client, such as homemaker services and medical bills Most auto repairs, unless the car is the only method of transport for a disabled or working member of the household Out of state travel, unless documentation of domestic violence, physical or mental instability can be attained Any item which does not truly prevent or avert crisis for the family. Process to obtain assistance: All Northeastern IL Case Management Cooperative staff will complete the Emergency Assistance application with clients who are requesting assistance. Staff will complete the application for the client requesting assistance and provide a detailed explanation of the emergency/crisis situation and provide the appropriate documentation. The client narrative must be specific in terms of the request for assistance and amount needed to resolve the crisis, which is an emergency situation that cannot be resolved by any other agency or means. The cap amount is 250.00 but actual payment amounts will be determined by the documentation submitted and situation described in the narrative. AFC will accept applications from Case Managers based on the designated calendar dates that will be provided at the start of the year. Applications received on those dates will be reviewed for eligibility. Case Managers will be notified the next business day if the request has been determined eligible. Responsibilities of Client/Applicant 1. Clients may request Emergency Assistance from a Ryan White, DRS, Corrections or Intensive Housing Case Manager. 2. Applicants must provide Case Managers with adequate documentation that there is an emergency situation that cannot be resolved by any other means.
3. Applicants must provide documentation that their household income is less than 50% of the median household income in the Chicago metropolitan area for their household size (per the official determination of the U.S. Department of Housing and Urban Development). Responsibilities of Agency/Case Manager 1. The Case Manager will meet with clients to obtain necessary documentation and review for eligibility 2. The Case Manager or agency designee will indicate in the application and inform the Emergency Services Associate of the desired payee. 3. Case Manager will make arrangements to obtain check from AFC or have it mailed to agency. 4. Case Manager will use check to pay the third party/vendor( purchase gift card, transit card ) 5. The agency must have documentation on file (such as a receipt) that assistance was used for the purpose intended and these receipts must be sent to the Emergency Services Associate at AFC in 10 business days. 6. Explanation of race codes on Client Service Form: A AI/AN NH/PI C B/AA AI/AN and C A and C B/AA and C NH/PI and C Other/Multi Asian American Indian/Alaskan Native Native Hawaii/Pacific Islander Caucasian Black/African American American Indian/Alaskan Native and Caucasian Asian and Caucasian Black/African American and Caucasian Native Hawaiian/Pacific Islander and Caucasian Other not listed/multi-racial Responsibilities of AFC: 1. AFC will cut a check to the appropriate third party/vendor and inform the case manager when it is available. No payments will be made directly to the applicant/client; all payments will be made directly to a third party/vendor (store gift card, transit card). Clients who are dissatisfied with the process or results of their application for Emergency Assistance will be provided the name and number of Housing Assistance Manager, Ric Martel, 312-334-0949 at AFC. FORMS: Emergency Assistance Application (Three Pages)
Emergency Fund Client Service Form Date: / / Agency: Center for Housing and Health 1. Client Information First Name Last Name Street address Zip Code Phone Number 1 Phone Number 2 Date of birth Hispanic Race Yes No A and C AI/AN and C NH/PI and C B/AA and C Marital/ Partnership Status Does the client have a disabling condition? Married/Partnered Single Yes No 2. Household Information First Name Last Name Age Hispanic Race Sex Yes No A and C AI/AN and C NH/PI and C B/AA and C M F Yes Yes Yes No No No A and C AI/AN and C NH/PI and C B/AA and C M F A and C AI/AN and C NH/PI and C B/AA and C M F A and C AI/AN and C NH/PI and C B/AA and C M F 3. Case Information a. Reason for assistance (select only one): Car repair Death in the family Displacement due to foreclosure Domestic violence Eviction Homelessness Household size increase or decrease Imprisonment Loss of delay of public benefits Maintain/enter subsidized housing Natural disaster New baby New job Work hours decreased/job loss Other: b. Were any of the following additional resources used: Agency Funds FEMA Church/Synagogue LIHEAP Other: c. Referral source: External Homelessness Prevention Call Center (HPCC) Internal Self d. Type and Amount of assistance: Electricity Gas Water Rent Mortgage Security deposit Moving costs Medical items Documents Child items Home items Transportation Child care Adult clothing Car repair Food Other: Total:
e. Please write a narrative about the client s situation and the impact of the assistance. Case Managers must be able to provide adequate documentation that there is an emergency situation that cannot be resolved by any other means. Be sure to include any case management or referrals you provided to the client and steps the client will take to increase their income and reduce their expenses. I have received the assistance described in this document, I understand that the information on this form will be shared with the Emergency Fund and I may be contacted by Emergency Fund staff to share my feedback about this assistance. X Client signature and date
AIDS FOUNDATION OF CHICAGO Emergency Assistance Request Form I am asking the AIDS Foundation of Chicago to provide financial assistance. I need to pay for:. Payee Name: Address: City, Zip: I give you permission to send the check directly to the person or company and to ask for a receipt. (initial or sign here) The information I have given you about my income, my expenses, my savings and my household is true. I understand that in signing this application and requesting this assistance, my name will be placed in AFC s Northeastern Illinois HIV/AIDS Case Management Cooperative Central Registry if it is not already in there. I understand that the Emergency Assistance program is not an entitlement program and that I am not guaranteed to receive assistance. I have given permission to have my most recent AFC Medical Assessment form included with this application. (client must initial) I understand that all of the information that I have provided in this application will be shared with The Emergency Assistance office including my medical information. (client must initial) I verify that the above information is accurate to the best of my knowledge. My Signature Case Manger Signature Printed Printed Today s Date Today s Date EMERGENCY ASSISTANCE Checklist: (make sure all of these are included with the application) EMERGENCY ASSISTANCE Client Service Form with detailed narrative EMERGENCY ASSISTANCE Request Form Proof of income AFC Medical Assessment form
Emergency Assistance Program Calendar AFC will accept applications from Case Managers based on the designated calendar dates below. Applications received on those dates will be reviewed for eligibility. Case Managers will be notified the next business day if the request has been determined eligible. Fax applications to Joseph Taylor @ 312-334-0977 Wednesday January 13, 2010 Thursday February 11, 2010 Tuesday March 9, 2010 Thursday April 8, 2010 Monday May 10, 2010 Thursday June 10, 2010 Friday July 9, 2010 Thursday August 12, 2010 Thursday September 9, 2010 Friday October 8, 2010 Thursday November 11, 2010 Thursday December 9, 2010