Helping Hand Referral Application (Law Enforcement/State Attorney Referral)

Application Process

Referral Source Confirmation:
1. Agency making referral (select one):
- Law enforcement agency
- State Attorney's Office for Pinellas, Pasco, or Hillsborough
- Victim advocates working in coordination with above agencies

2. Referral Agency Information
- Name of agency/department making referral
- Contact person name (first and last)
- Phone number of referral agency contact
- Email of referral agency contact
- Applicant photo ID (required)

Applicant Personal Information:
1. Full demographic information
- Full name (first, middle, last, suffix)
- Date of birth (month, day, year)
- Address (street, city, state, zip code)
- Phone number
- Email address
- Ethnic background (for statistical purposes only)

2. Household Information
- List of household member names and dates of birth (adults and children)

Employment Information:
1. Employment Status
- Currently employed? (Yes/No)
- Where currently employed (if employed)
- Explanation of unemployment (if applicable)
- Most recent pay stub (file upload required)

Financial Information:
1. Income and Expenses
- Total household monthly income (include job-related income, social security, cash assistance, child support)
- Total household monthly expenses
- Bank statements required upon request

2. Assistance Programs
- Receives food stamps? (Yes/No)
- If yes: amount per month
- Department of Children and Families (DCF) involved? (Yes/No)
- If yes: case worker name and phone number
- Receives housing assistance (HUD, Section 8, etc.)? (Yes/No)

Type of Assistance Needed:
1. Select all that apply:
- Utility assistance
- Transportation
- Visit to donation center (items include hygiene, kitchen supplies, bedding, cleaning supplies, clothing, etc.)
- DV safety assistance
- Child and baby needs
- Advice/resources
- Grocery assistance
- School supplies
- Holiday assistance
- Other

Circumstances and Background:
1. Detailed narrative
- Explanation of circumstances surrounding request for assistance
- Include background information and/or court case information

Criminal History:
1. Background check authorization
- Has applicant or anyone in household been arrested, convicted of, or plead guilty to a crime? (Yes/No)
- If yes: description of nature of crime and subsequent rehabilitation

Transportation:
1. Car/reliable transportation? (Yes/No)

Documentation Agreement:
1. Confirmation statement
- Agreement to provide supporting documentation upon final approval (Yes/No)

Application Statement and Consent:
1. Certification
- Applicant certifies all answers are true, accurate, and complete
- Understanding that omission/misrepresentation results in immediate rejection
- Authorization for background check and reference checks
- Agreement to abide by all Hands Across the Bay rules and regulations if assisted
- Understanding that application does not constitute guarantee of assistance
- Understanding that decision is contingent on successful completion of lawful pre-assistance checks

2. Privacy and Data Consent
- Agreement to privacy policy
- Confirmation that all information provided is true and accurate to best of knowledge
- Understanding that submission does not guarantee assistance
- Applications reviewed based on need and available resources