Financial Assistance Program
You have requested that we consider your application for Financial Assistance. To do so we will need your
help by providing information and documents that will enable us to determine eligibility. We would be happy
to help you with this process.
This is not an entitlement program. All applications will be screened diligently in accordance with all
federal, state and local regulations. Samaritan House funds are limited and restricted. Applications can be
processed only after all requested verification papers have been submitted. Please complete the attached
application. Answer all the questions to describe your situation. This application process takes time, so please
be patient. You may be asked to bring in additional forms or information in order for us to process your
application.
You must have lived and paid rent in Menlo Park or E. Palo Alto for the past 30 days or more, and have
proof that you currently live there (i.e. rent receipt, other documentation.)
Financial Assistance funds are primarily for a family with minor children, a senior or a disabled person.
There are very limited funds available occasionally for single adults without disabilities.
You must have a verifiable critical financial need (real need to relocate, or non-recurring emergency
situation, i.e. a 3 day pay or quit or a 30 day notice, utility shut off notice) and have tried all personal or
community resources before submitting this application.
You must have enough income to pay your rent in the future months in the housing you find. Your
must also be able to show that you cannot pay all or part of your apartment/housing entry cost or back
rent.
For security deposit requests you must have found housing, applied for it and been accepted. Funds
are only payable to the landlord and you will be asked to verify the landlord/owner.
No automatic eligibility. This is not an entitlement program. Eligibility is based on verified need,
residence, ability to maintain and willingness to address any underlying problems that may have
caused the financial crisis being experienced at the moment. No funds will be guaranteed to the
landlord until all verification requested has been submitted and the screening committee has
approved your completed application.
Your household’s ability to contribute towards the housing cost will be closely examined.
By signing below you acknowledge you have read and understand the terms of the Financial Assistance
Program.
Applicant Signature:_____________________________________Date:____________
Co-Applicant Signature:__________________________________Date:____________
Case Manager Signature:__________________________________Date:____________
1852 Bay Road • East Palo Alto, CA 94303 • (650)294-4312 • Fax (650)425-9338
www.samaritanhousesanmateo.org
Food • Shelter • Clothing • Counseling • Healthcare
Application Check List:
Name:______________________________________Date:______________
Before your application can be presented, all items checked on this form must be completed.
______Personal Statement
______Proof of Identification for each member of the household (i.e. picture ID, birth
certificate, Social Security, etc.)
______Budget Form
______Employment Verification for past 30 days (i.e. recent paycheck stubs)
______Other Income Verification (i.e. letters or statements from CalWorks, Child Support,
Social Security, Unemployment, Employment offer letter)
______Bank Statements for the last 3 months
______Verification of critical housing need: This may include eviction notice, notice of delinquent
rent, 3 day pay or quit or statements from other members of shared situation.
______Utility bills for the past 3 months and/or shut off notice
______Rental/Lease Agreement
______Any additional documentation deemed necessary to demonstrate the client’s situation or
need for assistance.
Also supply the following if checked below
______Documents related to COVID-19 temporary loss of income
______Auto registration and auto insurance policy
______3 estimates for auto repair
______Other
Total Amount Requested: $_____________
Total Housing Cost:
$_____________
Responda todas las secciones completamente:
Fecha de Nacimiento
Name ____________________, _________________________DOB______/______/____ Gender: M F
Nombre Last Name / Appellido
First Name /Primer Nombre
mm dd año (yy)
Sexo: hombre mujer
Address __________________________________________ City ________________________ Zip Code ________
Direccion
Ciudad
Codigo Postal
Telephone Number (____)________-____________ e-mail: ____________________________________
Numero de Telefono
Correo electrónico
Marital Status: Married Single
Widowed
Divorced
Other ____________
Estado Civil:
Casado/a Soltero/a
Viudo/a
Divorciado/a
Otro ____________
Race (circle all that apply) White Black Asian Amer Indian Native Hawaiian/Pacific Islander Other_______
Raza (circule los que aplica):
Blanca Moreno Asiatico IndioAmericano Nativo de Hawaii/Pacifico
Otro _______
Hispanic (check one)
Yes No
Primary Language: Spanish English
Other ______________
Hispano (marque uno):
No
Lenguaje Primario:
Español
Inglés
Otro
Emergency Contact:____________________________ Telephone Number (____)________-__________
Contacto de Emergencia:
Numero de Telefono
Household Members:
Miembros del hogar:
Name
Gender:
Date of Birth
Monthly Income
US
Country of Birth
Vet
Nombre
Sexo:
Fecha de Nacimiento
Ingresos Mensuales
Pais de nacimiento
Veterano
Citizen?
¿Ciudadano?
Highest level of education of applicant
0 - 8 yrs
9 - 12 yrs
12+ yrs
Máximo grado de Educación del cliente:
0 - 8 anos
9 - 12 anos
12+ anos
Seguro de Medico:
Ninguno
Kaiser Medi-Cal
Medicare
ACE Otro: ______________
Health insurance
None
Other
Non Cash Benefits Information: (check all that apply)
Información de benficios no monetarios (marca el que corresponde)
Food Stamps
WIC
CalWorks Transportation
Estampillas de Comida
WIC / Mujeres y ninos
Ayuda de transportacion
Section 8
CalWorks ChildCare
Sección 8
Ayuda para cuidado de niños
Budget Worksheet
Applicant(s) Name(s):____________________________________ Date: _______________________
MONTHLY GROSS INCOME
Last Month
This Month
Next Month
_______
_______
_______
Applicant’s gross income: Job #1
Applicant’s gross income: Job #2
Second Applicant’s gross income: Job #1
Second Applicant’s gross income: Job #2
Other Household Members’ Income
(combined)
SSI or SSDI benefit amount
Other income (circle all that apply):
Unemployment, Alimony, Child Support,
CalWORKS, General Assistance, Retirement,
Vet’s Pension, Other Pension
TOTAL MONTHLY INCOME
$
$
$
MONTHLY EXPENSES
Last Month
This Month
Next Month
_______
_______
_______
Rent
Utilities: PG&E/water/garbage
Telephone
Food
Health insurance
Medical (prescriptions, doctor’s visits, etc.)
Car payment
Auto Insurance
Transportation (bus, gas, tolls, parking)
Child care
Clothing
Toiletries
Laundry, cleaning, other household
Installment payments (credit cards or loans)
Indicate payment type:
Cable television
Internet
Miscellaneous (cigarettes, entertainment,
etc.)
TOTAL MONTHLY EXPENSES
$
$
$
TOTALS
Last Month
This Month
Next Month
_______
_______
_______
Total income (from Gross Income Section)
Less total expenses (from Expenses Section)
MONTHLY BALANCE
$
$
$
Personal Statement
Please describe in your own words why you are asking for financial assistance:
Applicant Name (please print):_______________________________________________
Applicant Signature: _________________________________________Date:__________
CLIENT CONSENT FOR CLARITY SYSTEM DATA COLLECTION AND
RELEASE OF INFORMATION
By signing this form, I authorize this agency, Samaritan House South and the agencies listed
below and attached to share information such as my name, date of birth, gender, race, ethnicity,
language(s) spoken, social security number, home address, phone number, photograph,
income, employment, asset and housing status information, information about assessments,
needs, services requested, services received, and other pertinent information about me and my
household members for the purpose of providing services including food, shelter, clothing,
transportation, housing assistance, utilities, assistance with benefit forms, tax preparation,
financial education and asset development, advocacy, landlord-tenant mediation and referrals
to other services.
The information that is collected in the Clarity database is protected by limiting access to the
database and by limiting with whom the information may be shared, in compliance with the
standards set forth by federal, state, and local regulations governing confidentiality of client
records. Every person and agency that is authorized to read or enter information into the
database has agreed to maintain the security and confidentiality of the information.
Core Service Agencies
Homeless Service Providers
Coastside Hope
Abode Services
Samaritan House
Daly City Community
San Mateo County Department
Home and Hope
Services Center
of Housing
San Mateo County Health
Fair Oaks Community Center
StarVista
System, Behavioral Health And
Recovery Services
Housing Authority of the
San Mateo County Human
Puente de la Costa Sur
County Of San Mateo
Services Agency
LifeMoves (formerly known
Tides/Pacifica Resource
Service League Of San Mateo
as InnVision Shelter
Center
County
Network)
Mental Health Association
Samaritan House
Mateo Lodge
Of San Mateo County
Next Step Center, Veterans
Samaritan House South
VA Palo Alto Health Care
Resource Center of
System (VAPAHCS)
America
YMCA Community Resource
San Francisco VA Health Care
Project WeHOPE
Center
System (SFVA)
Efforts are made to keep this list current, however there may be Core Service Agencies and/or
homeless service providers that begin to participate in the data system that are not included on
this list.
☐Additional agencies are listed in an attached document.
I UNDERSTAND THAT:
Use of my likeness in a photograph will be viewable by other partner agencies and
providers.
The Core Service Agencies and homeless service providers have signed agreements to
maintain the confidentiality and security of my information.
The release of my information does not guarantee that I will receive assistance, and my
refusal to authorize the use of my information does not disqualify me from receiving
assistance.
This authorization will remain in effect until I revoke it in writing.
My records are protected by federal, state, and local regulations governing confidentiality
of client records and cannot be disclosed without my written consent unless otherwise
provided for in the regulations.
CONSENT FOR RELEASE SIGNATURE
Yes, I authorize this agency and other partner agencies and their representatives to share
information about me and my household members for the purpose of providing the services that I
am requesting.
Client Name (Please Print)
Client Signature
Signature Date
OPT OUT
No, I do not authorize these agencies to share my confidential information.
Client Name (Please Print)
Client Signature
Signature Date
AGENCY USE ONLY
Personnel Name (Please Print)
Agency Personnel Signature
Signature Date
DISTRIBUTION: Signed original to Agency’s Client File