CHN Housing Partners Water/Sewer Assistance Application

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ATTENTION:


This application is only for the Water/Sewer Affordability and Sewer Crisis Assistance.



If you would like to apply for the Low Income Household Water Assistance Program (LIHWAP) you MUST schedule an appointment by calling 216.350.8008 or going online at   www.chn.itfrontdesk.com.  


Also, please note: 


The Water / Sewer Affordability Program and Sewer Crisis Assistance Program will NOT prevent a STOP or disconnection of your water / sewer services. Only a payment plan created by Cleveland Water for both your water and sewer accounts OR an appointment with the LIHWAP will assist with pending shut offs or reconnections of your water / sewer services.

 



Thank you for your cooperation.



Welcome to CHN Housing Partners Online Application for Water/Sewer Assistance.

How does it work?
The Water and Sewer programs are for residents who have utility bills paid to Cleveland Division of Water and Northeast Ohio Regional Sewer District. Income restrictions apply.

CHN is the entry point to access a broad array of housing, utility assistance, and referral resources, which you will be screened for. You will be under no obligation to participate in any programs we recommend. 

Fill out the online application in its entirety and gather a few documents:
   1. Photo identification for each household member over 18 years of age
   2. Proof of citizenship (birth certificate, Social Security card, naturalization certificate or passport) for all household members
   3. Current Water and / or Sewer Bill
   4. Proof of financial hardship - you must have a verifiable hardship within the last 6 Months (e.g. job loss, medical...)

For your convenience, CHN Housing Partners allows the use of e-signatures with this online form. You will be prompted to enter your name at the end of this form prior to submitting to give consent. If you have questions or need further assistance, please call our hotline at 888-901-1222.

Who qualifies?
Residents of the City of Cleveland and Cuyahoga County who are having difficulty making utility payments and who meet income eligibility requirements. 


Online Application Guidelines
To apply for programs with CHN Housing Partners, you must complete an application with us along with providing documents to verify the information submitted. Each participant in this program is required by the Department of Housing and Urban Development to provide their annual income level to establish eligibility for this federally-funded program, and to verify race/ethnicity for data collection purposes only. We have split this into the following sections:

1. Application information: Your contact and demographic information
2. Household members: Other members of your household and their demographic information
3. Income sources: All sources of income and public benefits for the past 60 days for all household members over 18
4. Housing & utility details: Details about your rent/mortgage and utilities for program-specific purposes and to help us assess what program(s) you may need
5. Document upload: We will request scanned copies, legible photos or screenshots of documents as verification for your eligibility for programs. 

You may encounter a slow system or downtime due to a high volume of traffic on the site. Please use the "Save my progress and resume later" feature located at the top of the form OFTEN to avoid losing any information. (This form is powered by FormAssembly.)


Fair Housing Act (42 USC 3600, et seq.)
If you have an impairment, disability, language barrier, or otherwise require an alternative means of completing this form or accessing information about our services, please talk to us about arranging alternative accommodations. We serve all clients regardless of income, race, color, religion/creed, sex, national origin, age, family status, disability, or sexual orientation/gender identity. We administer our programs in conformity with local, state, and federal anti-discrimination laws, including the federal Fair Housing Act (42 USC 3600, et seq.)


Click Next Page to Continue

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Applicant and Co-Applicant Details

In this section, please enter your most up to date contact information and demographic information.

CHN Housing Partners (CHN) is committed to assuring the privacy of individuals and/or families who have contacted us for assistance. We realize that the concerns you bring to us are highly personal in nature. We assure you that all personal information shared verbally and/or in writing will be managed within ethical and legal consideration. Additionally, we want you to understand how we use the personal information we collect. Please carefully review this notice as it describes our policy regarding the collection and disclosure of your nonpublic, personal information.
 
CHN's Privacy Policy

The Applicant (and Co-Applicant, if applicable) should be an adult member of your household that will be able to represent, provide information for, and make decisions on behalf of your household. 


Please prepare for upload: Photo Identification and Social Security Cards for each Applicant and Co-Applicant.

Applicant Information

















Enter date in MM/DD/YYYY format










Please select the Agency that helped you complete this Application or made you aware of it



Co-Applicant Information










Enter date in MM/DD/YYYY format








Need help? Call our hotline at 888-901-1222.

WARNING: The information provided on this form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.

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Household Members

Please enter additional members who reside in your household (i.e. children, dependents, other family members, etc.). Use the "Add Additional Household Member" link to add as many as you need.

You do not need to re-enter Applicant or Co-applicant (if applicable) information here.


Please prepare for upload: For each household member, be prepared to provide verification that they are your dependents - such as Social Security Cards and Birth certificates

Household Member


Enter date in MM/DD/YYYY format











Need help? Call our hotline at 888-901-1222.

WARNING: The information provided on this form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.

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Current Income Sources and Public Benefits


Please enter all sources of Income and Public Benefits that your household have recieved for the past 60 days, for all household members over the age of 18. 


Use the "Add Additional Income Source" link to add as many as you need


Current Annual Income is the estimated income for the current year including any wages,

benefits, alimony, child support and other forms of financial income or support.


Income includes: Full-time employment, part-time employment, self-employment, spousal support, child support, investment income, Social security, SSI, SSDI, income from assets, pension/annuity, unemployment, adoption subsidy, short term disability, long term disability, veteran's benefits, zero income, family contribution, other

Public benefits include: Food stamps, WIC, ADC, OWF/TANF, rental subsidy, utility allowance, other public benefit

Please prepare for upload: Verification of income for the past 60 days - pay stubs, employment letters, award letters, etc.


Current Income or Public Benefit Source

Enter the Household Member who this income belongs to


Provide the Job Title for Employment types, if applicable
Please take the total income you received in the last 30 days and multiply by 12 to determine your annual income:

Please estimate to the best of your ability. Our staff will review your documents and provide a full eligibility determination.
Need help? Call our hotline at 888-901-1222
WARNING: The information provided on this form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.

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Household and Utility details

We will be asking more specific questions about your Housing Details here, including your living situation, rent amount, and utility details. This information will allow for us to screen eligibility for the wide range of programs we offer. You will be under no obligation to participate in programs we recommend.

Please prepared for upload: Copies of utility bills for all utilities and additional verification as requested in each section that follows
Housing





Utilities


Please provide information for all utilities you are responsible to pay for, even if your name is not on the bill. We will be able to assess your ability to receive assistance payments and/or discount programs that we administer. Utility assistance is separate from rental assistance and will not affect your application for rental assistance.
Electric





Gas





Water





Sewer





Hardship Statement



We require a statement of Hardship that helps explain why you need assistance. Please select the category that represents the primary hardship reason and any additional detail in the Hardship Statement. You will be required to submit documentation of your hardship. Hardship must have occurred within the past six months.


Please briefly explain your hardship here:

up to 255 characters
Need help? Call our hotline at 888-901-1222.

WARNING: The information provided on this form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.

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Upload Documents

Please use this page to upload documents that support your application. You can attach electronically downloaded documents, use a scanner, or take pictures or screenshots of your documents with your phone.

You can upload multiple files per section by using the "Add another ..." link. There is a limitation of 20 files per form.

Gather the required documents:
1. Photo identification for all household members 18 years or older
2. Verification of household members (Social Security card preferred, or birth certificate) for all household members
3. Income Documents to verify all income received in the last 60 days - paystubs, benefit statements, etc.
4. Utility Bills for those you are responsible for paying so we can assess for assistance and discount programs
5. Hardship Documentation - (e.g. job loss, medical...) Must have occurred within the past six months.


Complete applications with all required supporting documents will be processed faster - please upload as much as you are able to and ensure you have documents for each section!  


If taking photos with your phone/camera, you can line up your IDs and Social Security cards within one image, instead of one at a time
ID

Utility Bills
Upload Utility Bills in each section listed here based on programs you are requesting assistance for.






Need help? Call our hotline at 888-901-1222.
WARNING: The information provided on this form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.

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Acknowledgement & Submit

I/we certify that all provided information is correct to the best of my knowledge and have received a copy of CHN's Privacy Policy. I/we authorize CHN Housing Partners to verify all information contained on this online form and to pull my credit report. I/we understand that I may be assisted by federal funds which carry severe penalties, including incarceration.


By typing my full name below, I hereby authorize CHN to release nonpublic personal information it obtains about me to any third parties necessary to provide me with the services I requested. I acknowledge that I have read and understand the above privacy practices. I understand I will receive a copy of all information submitted at the email address I provided on Page 2, "Applicant E-mail Address".

WARNING: The information provided on this form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.