GULF COAST COMMUNITY SERVICES ASSOCIATION, Inc.
`Department
of Client Services
2015 Application for Services
Revised: January 2015
FOR OFFICE USE ONLY
Date: ___/___/_______
Time: ____:______ am/ pm
Initials: ________
Dear Applicant:
Dear Applicant,
Thank you for your interest in the 2015 Client Services. Enclosed you will find an application for
assistance along with detailed instructions to help you accurately complete your application. Please
note that a signed, completed application and all required documents must be submitted in order for
your application to be processed in a timely manner. Failure to submit the required documentation
listed below will result in delayed processing or denial of your application.
If you are determined eligible, a GCCSA representative will be assigned to work with you on an ongoing basis. A GCCSA Representative will attempt to contact you via phone to schedule an
appointment to discuss needs and potential service elements. No more than three (3) attempts will be
made to contact for an appointment. If you are not eligible to receive services you will be notified via
mail at the address provided in the application.
Copies of the following documents should accompany the completed application for determining
eligibility to receive services.
2015 GCCSA Application for Services Checklist
See attached “WHAT DO I NEED” WORKSHEET* page for a detailed explanation of required
documentation for each Household Member:
-10, complete all questions
1. Picture Identification* (copy must be legible)
2. Proof of Harris County Residency*
– Must submit proof of current income for all household members eighteen (18) years of
age and older. Must be consecutive payment periods and within last thirty (30) days of the completed
application date
Current, signed Lease Agreement (all pages) with Rental Concession Addendum/Renewal
Agreement/Housing Re-Certification are required, if applicable
Electric Bill Assistance, submit a front and back copy of your current electric bill showing
service address (must have all other items listed above)
*For a detailed list of required documents, please refer to the “What Do I Need” Worksheet,
available at GCCSA Lobby and online.
GCCSA DOES NOT MAKE COPIES. SUBMIT COPIES WITH THE APPLICATION.
INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED
Have a question about the GCCSA Application: Visit www.GCCSA.org or Call: 713-393-4700
Complete Applications may be submitted, in person at
GCCSA Corporate Office and Community Learning Center
**Monday and Tuesday 8:30AM – 4:00PM
**Dates and Times subject to change. Visit www.GCCSA.org for most recent information
WARNING: Title 18, Section 1001 of the U.S. Code makes it a criminal offense to make willful false statements or
Page
of 10 States as to any matter within its jurisdiction.
misrepresentation to any department or agency in
the2United
Revised January 2015
PART ONE – HOUSEHOLD INFORMATION
First Name
Last Name
Social Security No.
-Street address: (include Apartment No., if applicable)
Mailing Address (If different from above)
 Is this an “In Care Of” Address
Personal Email Address:
City, State
County
Zip Code
City, State
County
Zip Code
Mobile phone no.:
Home phone no.:
(
(
)
--
)
ALTERNATE CONTACT NAME / NUMBER (REQUIRED)
First Name (Not a household member)
Last Name
Relationship to Applicant
Relative
Personal Email Address:
Mobile phone no.:
Home phone no.:
(
(
)
/
Friend
/
(Circle One)
Co-Worker
)
ALTERNATE CONTACT NAME / NUMBER (OPTIONAL)
First Name
Last Name
Relationship to Applicant (Circle One)
Relative
Personal Email Address:
Mobile phone no.:
Home phone no.:
(
(
)
LIST ALL OTHER HOUSEHOLD MEMBERS
Name (First and Last Name)
1.
2.
/
Friend /
Co-Worker
)
TYPE OF HOUSEHOLD
Phone Number
(
)
(
)
Social Security No.
--
--
--
--
3.
(
)
--
--
4.
(
)
--
--
5.
(
)
--
--
 Single Parent-Female
 Single Parent-Male
 Single Person
 Two Parent Household
 Two Adults, No Children
 Other
OTHER
If more than 6 members in the Household, please use and attach an additional page.
 Receive Food Stamps
 Farmer
 Migrant Farmworker
 Seasonal Farmworker
$ ______________
HOUSING
 Apartment
 Homeless
 Homeowner
 Other___________
(please specify)
Page 3 of 10
Revised January 2015
WARNING: Title 18, Section 1001 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentation to any department or agency in the United States as to any matter within its
jurisdiction.
PART TWO - HOUSEHOLD DEMOGRAPHICS
NAME
(First and Last)
Relationship
to Applicant
SELF / HEAD OF
HOUSEHOLD (HH)
Household Member #2
Household Member #3
Household Member #4
Household Member #5
Household Member #6
 Co-head of HH
 Spouse
 Other Adult
 Child (Son/Daughter)
 Other, specify________
 Co-head of HH
 Spouse
 Other Adult
 Child (Son/Daughter)
 Other, specify________
 Co-head of HH
 Spouse
 Other Adult
 Child (Son/Daughter)
 Other, specify________
 Co-head of HH
 Spouse
 Other Adult
 Child (Son/Daughter)
 Other, specify________
 Co-head of HH
 Spouse
 Other Adult
 Child (Son/Daughter)
 Other, specify________
Birthdate
and
Age
(MUST COMPLETE ALL BOXES)
Gender
Date
 Male
 0-8 grade
/
 Female
 9-12/Non-grad
/
 H.S. grad/ GED
 12+ Post Sec.
_______
Age
Date
 Male
/
 Female
/
_______
Age
Date
 Male
/
 Female
/
_______
Age
Date
 Male
/
 Female
/
_______
Age
Date
 Male
/
 Female
/
_______
Age
Date
 Male
/
 Female
/
_______
Age
Race
(Select One)
Education
 2 or 4 Year Degree
 0-8 grade
 9-12/Non-grad
 H.S. grad/ GED
 12+ Post Sec.
 2 or 4 Year Degree
 0-8 grade
 9-12/Non-grad
 H.S. grad/ GED
 12+ Post Sec.
 2 or 4 Year Degree
 0-8 grade
 9-12/Non-grad
 H.S. grad/ GED
 12+ Post Sec.
 2 or 4 Year Degree
 0-8 grade
 9-12/Non-grad
 H.S. grad/ GED
 12+ Post Sec.
 2 or 4 Year Degree
 0-8 grade
 9-12/Non-grad
 H.S. grad/ GED
 12+ Post Sec.
 2 or 4 Year Degree
Ethnicity
(Select One)
 Black/Afr. American
 White
 American Indian or Alaskan
Native
 Asian
 Multi-race
 Other
Hispanic/Latino
 Black/Afr. American
 White
 American Indian or Alaskan
Native
 Asian
 Multi-race
 Other
 Black/Afr. American
 White
 American Indian or Alaskan
Native
 Asian
 Multi-race
 Other
Hispanic/Latino
 Black/Afr. American
 White
 American Indian or Alaskan
Native
 Asian
 Multi-race
 Other
 Black/Afr. American
 White
 American Indian or Alaskan
Native
 Asian
 Multi-race
 Other
Hispanic/Latino
 Black/Afr. American
 White
 American Indian or Alaskan
Native
 Asian
 Multi-race
 Other
Hispanic/Latino
 Not Hispanic/Latino
Other
 No Health
Insurance
 Disabled
 Veteran
 Not Hispanic/Latino
 No Health
Insurance
 Disabled
 Veteran
Hispanic/Latino
 Not Hispanic/Latino
 No Health
Insurance
 Disabled
 Veteran
 Not Hispanic/Latino
 No Health
Insurance
 Disabled
 Veteran
Hispanic/Latino
 Not Hispanic/Latino
 No Health
Insurance
 Disabled
 Veteran
 Not Hispanic/Latino
 No Health
Insurance
 Disabled
 Veteran
If there are more than 6 members in your household, please use and attach an additional page.
Page 4 of 10
Revised January 2015
WARNING: Title 18, Section 1001 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentation to any department or agency in the United States as to any matter within
its jurisdiction.
To properly complete PART THREE - Income Sources Table, please refer to the “WHAT DO I NEED” Worksheet.
For all Income Sources selected, GCCSA requires applicants to provide copies of documents for verification.
PART THREE - INCOME SOURCES
NO INCOME
How often are
Employed? you paid?
 YES
 Weekly
 Twice, Monthly
 NO
 Bi-weekly
 SELF
Monthly
EMPLOYED
 Other
______________
Other Sources of Income (check all that apply)
Documentation required for all Income Sources selected.
 Paid in Cash
TANF
 SSDI / SSI / RSDI
 Unemployment Comp
 Social Security
 Farm Income
 Railroad Retirement
 Strike Benefits
 Worker’s Comp
 Training Stipends
 Alimony
 VA Benefits
 Military Allotments
 Pensions
 Dividends
 Court-ordered Child
Support
 Capital gains
 Sale of property
 Payment, Welfare Agency
 1x insurance payment
 Housing pay to the military
 College Scholarship and/or
grants
 Asset Depreciation
 Non-farm/Farm housing rent
 Medicare, Medicaid, Food
Stamps and School Lunch
 Housing assistance and
combat zone
 Depreciation for farm or
business assets
 Reverse mortgages
 Foster Children payments
 Other________________
 I have no proof of
income for the last
30 days.
Household Member #2
 YES
 NO
 SELFEMPLOYED
 Weekly
 Twice, Monthly
 Bi-weekly
 Monthly
 Other
______________
 Paid in Cash
TANF
 SSDI / SSI / RSDI
 Unemployment Comp
 Social Security
 Farm Income
 Railroad Retirement
 Strike Benefits
 Worker’s Comp
 Training Stipends
 Alimony
 VA Benefits
 Military Allotments
 Pensions
 Dividends
 Court-ordered Child
Support
 Capital gains
 Sale of property
 Payment, Welfare Agency
 1x insurance payment
 Housing pay to the military
 College Scholarship and/or
grants
 Asset Depreciation
 Non-farm/Farm housing rent
 Medicare, Medicaid, Food
Stamps and School Lunch
 Housing assistance and
combat zone
 Depreciation for farm or
business assets
 Reverse mortgages
 Foster Children payments
 Other________________
 I have no proof of
income for the last
30 days.
Household Member #3
 YES
 NO
 SELFEMPLOYED
 Weekly
 Twice, Monthly
 Bi-weekly
 Monthly
 Other
______________
 Paid in Cash
TANF
 SSDI / SSI / RSDI
 Unemployment Comp
 Social Security
 Farm Income
 Railroad Retirement
 Strike Benefits
 Worker’s Comp
 Training Stipends
 Alimony
 VA Benefits
 Military Allotments
 Pensions
 Dividends
 Court-ordered Child
Support
 Capital gains
 Sale of property
 Payment, Welfare Agency
 1x insurance payment
 Housing pay to the military
 College Scholarship and/or
grants
 Asset Depreciation
 Non-farm/Farm housing rent
 Medicare, Medicaid, Food
Stamps and School Lunch
 Housing assistance and
combat zone
 Depreciation for farm or
business assets
 Reverse mortgages
 Foster Children payments
 Other________________
 I have no proof of
income for the last
30 days.
NAME
(First and Last)
Applicant / Self
To report Income Sources for Household Members 4 - 6, see next page (Page 6).
Page 5 of 10
Revised January 2015
(Applicable if only other
areas not selected)
To properly complete PART THREE - Income Sources Table, please refer to the “WHAT DO I NEED” Worksheet.
For all Income Sources selected, GCCSA requires applicants to provide copies of documents for verification.
PART THREE - INCOME SOURCES (CONTINUED)
NO INCOME
How often are
Employed? you paid?
 YES
 Weekly
 Twice, Monthly
 NO
 Bi-weekly
 SELF
Monthly
EMPLOYED
 Other
______________
Other Sources of Income (check all that apply)
Documentation required for all Income Sources selected.
 Paid in Cash
TANF
 SSDI / SSI / RSDI
 Unemployment Comp
 Social Security
 Farm Income
 Railroad Retirement
 Strike Benefits
 Worker’s Comp
 Training Stipends
 Alimony
 VA Benefits
 Military Allotments
 Pensions
 Dividends
 Court-ordered Child
Support
 Capital gains
 Sale of property
 Payment, Welfare Agency
 1x insurance payment
 Housing pay to the military
 College Scholarship and/or
grants
 Asset Depreciation
 Non-farm/Farm housing rent
 Medicare, Medicaid, Food
Stamps and School Lunch
 Housing assistance and
combat zone
 Depreciation for farm or
business assets
 Reverse mortgages
 Foster Children payments
 Other________________
 I have no proof of
income for the last
30 days.
Household Member #5
 YES
 NO
 SELFEMPLOYED
 Weekly
 Twice, Monthly
 Bi-weekly
 Monthly
 Other
______________
 Paid in Cash
TANF
 SSDI / SSI / RSDI
 Unemployment Comp
 Social Security
 Farm Income
 Railroad Retirement
 Strike Benefits
 Worker’s Comp
 Training Stipends
 Alimony
 VA Benefits
 Military Allotments
 Pensions
 Dividends
 Court-ordered Child
Support
 Capital gains
 Sale of property
 Payment, Welfare Agency
 1x insurance payment
 Housing pay to the military
 College Scholarship and/or
grants
 Asset Depreciation
 Non-farm/Farm housing rent
 Medicare, Medicaid, Food
Stamps and School Lunch
 Housing assistance and
combat zone
 Depreciation for farm or
business assets
 Reverse mortgages
 Foster Children payments
 Other________________
 I have no proof of
income for the last
30 days.
Household Member #6
 YES
 NO
 SELFEMPLOYED
 Weekly
 Twice, Monthly
 Bi-weekly
 Monthly
 Other
______________
 Paid in Cash
TANF
 SSDI / SSI / RSDI
 Unemployment Comp
 Social Security
 Farm Income
 Railroad Retirement
 Strike Benefits
 Worker’s Comp
 Training Stipends
 Alimony
 VA Benefits
 Military Allotments
 Pensions
 Dividends
 Court-ordered Child
Support
 Capital gains
 Sale of property
 Payment, Welfare Agency
 1x insurance payment
 Housing pay to the military
 College Scholarship and/or
grants
 Asset Depreciation
 Non-farm/Farm housing rent
 Medicare, Medicaid, Food
Stamps and School Lunch
 Housing assistance and
combat zone
 Depreciation for farm or
business assets
 Reverse mortgages
 Foster Children payments
 Other________________
 I have no proof of
income for the last
30 days.
NAME
(First and Last)
Household Member #4
(Applicable if only other
areas not selected)
If there are more than 6 members in your household, please use and attach an additional page.
WARNING: Title 18, Section 1001 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentation to any department or agency in the United States as to any matter within
its jurisdiction.
Page 6 of 10
Revised January 2015
PART FOUR - REFERRAL INFORMATION
How did you learn about GCCSA services?
 Television Advertisement
 Social Service Agency
 Flyer
 2-1-1 United Way Hotline
 GCCSA Website / Internet
 Newspaper Advertisement
 Radio Advertisement
 A Former GCCSA Client
 Other: Please specify: ______________
Are you, or a Household Member a previous client of GCCSA?  YES  NO
If YES, please specify past history with GCCSA:  0-2 years
 3-5 years
 5+ years
Indicate the situation and/or circumstances that have led to you requesting GCCSA Services.
 Recent Divorce / Separation
 Job Loss
 Relocated to the area
 Eviction
 Unexpected Expenses
 Other, please specify: __________________________________________
How may we assist you in your current situation? Through Case Management and linkages to Community Partners,
GCCSA offers various services to address household needs.
Please specify all GCCSA services of interest to your Household:
 Rental Assistance
 Head Start/ Early Head Start
 IDA Program
 Utility Assistance
 Food Pantry
 Transportation Assistance
 GED/ ABE / ESL / SSL
 Housing Counseling
 Youth Initiative / EYES Program
 Parenting Classes
 Job Readiness Training
 Scholarship / Vocational Training
 Financial Literacy
 School Supplies / Holiday Initiative  Senior Services LINKS AARP
 Computer Class
 Nutrition Program
 Prescription Assistance
Other, please specify:
Please specify, Preferred Contact Time
GCCSA will make an effort to contact you when convenient for you.
Preferred Contact Phone Number: (
)
Complete Applications may be submitted, in
person at:
GCCSA Corporate Office
9320 Kirby Drive, Houston, TX 77054
-11
Select all that apply:
 AM
 PM
 Anytime, Monday - Friday
**Monday and Tuesday 8:30AM – 4:00PM
Other Time, please specify: ________________________
No More than three (3) attempts will be made to contact
you via phone.
**Dates and Times subject to change. Visit
www.GCCSA.org for most recent information
Page 7 of 10
Revised January 2015
Before signing the Applicant Certification,
HAVE YOU DONE THE FOLLOWING…
 Reviewed the “What do I Need” Worksheet
 Reviewed entire Application for completeness
 Made copies of all required documentation. GCCSA does not make copies of documents.
 Provided verification for all Income Sources, for past 30 days (All Household Members)
 Provided a stable contact Phone Number. Remember, GCCSA will make no more than three (3)
attempts to contact you via phone
Page 8 of 10
Revised January 2015
Applicant Certification
PLEASE READ CAREFULLY BEFORE SIGNING.
By signing below, I
following statements:
(Print Applicant Name) acknowledge the
1. I attest the information provided in this application is true and correct to the best of my knowledge and
belief.
2. I understand that no more than three (3) attempts (via phone) will be made by a GCCSA representative to
schedule an appointment for GCCSA services plan.
3. I understand my household income will be annualized, at the time of the submitted application, based on
pre-established agency procedures and the Texas Administrative Code (TAC).
4. I understand I may appeal a denial of eligibility, amount of assistance received or a delay of service(s).
5. I authorize the Texas Department of Housing and Community Affairs and its contracted agencies to
solicit/verify information provided on this application.
6. I understand that completion and submission of this application does not guarantee services.
7. I understand that I am responsible for providing copies of support documentation. GCCSA does not make
copies of documentation.
8. I understand that after one year, a request for my application documents will be subject to the policy and
procedures as outlined in the Open Records Request, and may require a fee for service.
9. I AM AWARE THAT I AM SUBJECT TO PROSECUTION AND/OR FINES UP TO $10,000 FOR
PROVIDING FALSE OR FRAUDULENT INFORMATION. Title 18, Section 1001 of the U.S. Code makes
it a criminal offense to make willful false statements or misrepresentation to any department or agency in
the United States as to any matter within its jurisdiction.
Applicant / Head of Household Name (Print)
Applicant Signature
Date
Page 9 of 10
Revised January 2015
About Gulf Coast Community Services Association, Inc.
The Gulf Coast Community Services Association, Inc. (GCCSA) is a 501(c)(3) Community Action
Agency founded in 1965. Today, GCCSA has established itself as one of the most experienced
community service providers in the gulf coast region and the largest Community Action Agency in the
state of Texas.
Purpose
Gulf Coast Community Services Association (GCCSA) exists to strengthen the educational, social, and
economic well-being of individuals and families as they move toward independence and self-sufficiency.
Organizational Intent
To earn confidence from the citizens of Harris County so that GCCSA becomes the exemplary model for
social services and community leadership.
General Inquiries and Frequently Asked Questions
Additional Information
Details of Services and Programs
GCCSA Head Start and Early Head Start Centers
Apply for Employment with GCCSA
Leave Feedback Regarding Services
Website: www.GCCSA.org
Email: services@gccsa.org
Page 10 of 10
Revised January 2015