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Central Ohio Area Agency on AgingHousing Assistance ProgramUpdated 1/Street Address /24Central Ohio Area Agency on AgingHousing Assistance ProgramApplication AgreementI, understand and agree to the following:- This is an application and not approval of payment.- I understand that I must be facing housing instability due to a documented & unforeseeable hardship.- Financial assistance is not an entitlement and is not guaranteed. Awards of financial assistance are based on many factors, including the potential for long-term housing stability and the availability of other resources.- This is a one-time assistance only.- All information that I provide will be kept confidential. By signing this form I consent to the collection of data and information that will be shared with the funder and your landlord/apartment management/mortgage provider for purposes of evaluating need for assistance.- I understand that documentation is required to support hardship of need and to verify age, income, and assets to complete the application process.- COAAA Housing Assistance Program coordinators (HAP)/COAAA case managers/partner agency case managers can exchange information electronically and/or by phone with housing providers, including my current landlord and/or prospective landlord, to assist me in sustaining & maintaining housing, as well as utility companies who service the address at which applicant resides.- All information I provide is complete and accurate to the best of my knowledge. Evidence of knowingly providing inaccurate information can be grounds for denial of assistance.- Full or partial payment may be awarded, and cannot be appealed.- All requests for financial assistance must be reviewed and approved by the COAAA Housing Assistance Program Manager, fiscal staff, and/or agency director to ensure compliance with program guidelines and funder requirements.- Awards are based on landlord/owner/manager rent verification, or utility company verification, as well as partner agencies who may pledge financial support, and acceptance of 3rd party payments.- Checks are made payable only to owner/facility/management company/mortgage provider/utility company.- When appropriate, COAAA HAP coordinators may require applicants to enter agreement with community service providers in order to ensure stable and sustainable housing and living conditions. Refusal of these terms could result in denial of assistance. I am requesting assistance for in the amount of $ .Applicant Signature Date Additional questions can be directed to the COAAA Housing Assistance Program at PHONE NUMBER AVAILABLE