Apply for Homeless Prevention Services

In spaces below, please fill in ALL household members.

Relationship to Applicant

Client Agreement:

I declare that the information I have provided Harford Community Action Agency (HCAA) is true, correct and complete. I understand that when this application is signed, permission is given to the HCAA to check all household income, bank accounts, housing expenses, insurance, and other benefits.

If I currently receive or have ever received benefits from the programs administered by the Harford County Department of Social Services (DSS), by signing this application, I give permission to the DSS to share with HCAA any information in my DSS case file needed to complete this application. Such information includes, but is not limited to, household members, income, expenses, resources, child support payments, etc.

I acknowledge that my application information will be stored digitally in the agency database: CAP60. This information will be maintained with the utmost confidentiality, and only HCAA staff will have access to individual files within the database.

Maryland has a fraud law. Punishment can occur for not telling the truth when applying for assistance from any HCAA program.

Harford Community Action Agency, Inc. prohibits discrimination in all its programs and activities on the basis of race, color, national origin, sex, religion, age, disability, political beliefs, sexual orientation, or marital or family status.

Grievance Process:

If the client wishes to file a grievance, they may do so in writing to the Executive Director stating the situation and their concerns. The Executive Director must set up an appointment with the client within 14 days of receipt of the letter of grievance to discuss the grievance and reach a solution. The client may speak to the Executive Director or Assistant Director, if available, during their application process.