WRAP Around Fund Application
For Kennebec, Somerset, Androscoggin, Franklin, and Oxford Counties
Wrap-fund Application: The following Wrap-fund application MUST have the following items (1-9)
completed prior to review of each application.
1. All Wrap-funds applications submitted are legible, in black or blue ink, and completed with all
required information. A Wrap-funds application submitted and not completed shall be marked
incomplete and returned to the Applicant to resubmit.
Date of Application:
Requesting Applicant Name:
Applicants Mailing Address:
City:
Zip Code:
County: ________________________________________Telephone Number:
Applicants Social Security Number:
(required)
Applicants Case Manager/Agency and Contact information if applicable:
__________________________________________________________________________________________
__________________________________________________________________________________________
Do you have a Representative Payee?
Yes
No
If Yes, please provide:
Name:
Agency:
Phone Number:
Email:
2. All Wrap-fund applicants are either eligible for or enrolled in Section 17 Services of the most recent
version of the MaineCare Benefits Manual. Note: eligibility or enrollment must be verified by the
Provider.
Please submit page 1 of current APS Section 17 authorization or please complete Section 17 eligibility
form on pages 6 & 7 of this application.
PO Box 358, Fairfield, ME 04937 www.assistanceplus.com
1-800-781-0070 ext 426(207) 453-4708 ext 426Fax (207) 238-6302
3. Each Wrap-fund application includes all house hold income, assets and benefit resources. All
information must be verified.
Applicant
Source
Family Member 1
Family Member
2
Family Member 3
Social Security Income
Public Assistance Payments
(TANF, GA, etc.)
Employment
Child Support
Alimony Received
Worker’s Compensation
Other Income:
TOTAL
GRAND TOTAL OF ALL FAMILY MEMBERS: $ _______________ (add total of Applicant + Family
Members)
Do you receive Food Stamps? Yes
No Amount: $__________
Do you receive Section 8 or some other Housing Subsidy?
Yes
No
IF NO, are you on a waitlist?
Yes (Agency:
)
4. Each Wrap-fund application includes current household monthly expenses. All information
must be verified.
Category
Household
Expenses
Rent/mortgage payment/lot
rent
Alimony paid
Child support paid
*Transportation expense
**Heating expense
**Electric expense
**Water & Sewer
Cell phone
Telephone/Internet/Cable
(circle)
Total
Category
Groceries
Household
Expenses
(not
paid
by
Food
Stamps)
Medical co-pays
Child care expense
Pet care expense
Other necessary expenses:
1.
2.
3.
4.
Total
GRAND TOTAL OF HOUSEHOLD EXPENSES : $
(add both Household Expense columns)
*Transportation expenses include payment, fuel, maintenance, inspections/tags, and insurance. Public
transportation can be listed under other necessary expenses.
**If heating, electric, water and sewer is included in rent, write INCLUDED.
1. Are you behind in any of your bills?
Yes
No
If Yes, please explain:
_______________________
__________________________________________________________________________________
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PO Box 358, Fairfield, ME 04937 www.assistanceplus.com
1-800-781-0070 ext 426(207) 453-4708 ext 426Fax (207) 238-6302
Any other information you would like to be considered (use an additional sheet of paper and attach to the
application.
5. All documentation requested on the application is verified by a 3rd party and attached to the Wrapfund application.
6. Verification of other resources (i.e. General Assistance, Section 8 housing, LHEAP, Salvation Army,
etc.).
Organization
Phone Number Outcome
7. All approved applications requests for Wrap-funds must fall under the following Wrap-fund needs
and Wrap-fund Allowable Amounts as described in Table A. (Wrap-funds can be used for housing or
emergency needs, but not both within the State fiscal year of July 1, 2015 –June 30, 2016.) Funds may
be used for more than one (1) need below, but cannot exceed $500.00 per State fiscal year per
Applicant for non-Housing Assistance.
Security Deposit or Rent Assist may exceed $500 and will make up the total allowance for the
applicant for state fiscal year of July 1, 2015 –June 30, 2016. If approved, applicant cannot apply for
Wrap-funds until the start of the next state fiscal year, July 1, 2016.
Wrap funding will not pay for: telephone payments, vehicle payments, vehicle insurance, vehicle
registration, cable bills; mental health services, any legal services/representation, additional funding stream
for contracting agencies, Court ordered DEEP or offender treatment; purchasing computers; car repairs,
which exceed 60% of the vehicle’s Kelley Blue Book value, or when other transportation resources are
available; debt consolidation or credit counseling services; internet services; payment of property taxes, and
medical care and treatment costs, which are covered by an insurance program, are elective in nature, or
deemed not medically necessary, as determined by a healthcare professional.
1. Is this an emergency need?
Yes
No if no, you are not eligible for Wrap funds
2. Please provide as much detail as possible as to why you are requesting WRAP Funding, use an
additional sheet and attach to application if needed. The requests are reviewed by a Wrap fund committee
that does not know you and your circumstances behind the need. The most current and concise
information you can provide will be helpful.
___________________________________________________________________________________
__________________________________________________________________________________
___________________________________________________________________________________
__________________________________________________________________________________
___________________________________________________________________________________
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PO Box 358, Fairfield, ME 04937 www.assistanceplus.com
1-800-781-0070 ext 426(207) 453-4708 ext 426Fax (207) 238-6302
3. Is this a step towards a resolving the emergency need?
Yes
No
If No, please explain:
________________________________________________________________________________
_________________________________________________________________________________
________________________________________________________________________________
_________________________________________________________________________________
Table A
Wrap-fund Needs
Rent
Security Deposit
Temporary Housing in a motel
Prescribed Medications up to 2 weeks
supply
Electric bill to maintain power in the
applicant’s house.
Emergency Fuel
Vision /Eye Care
Oral/Dental Care
Transportation to include car repairs and
transportation to access mainstream
services
Other emergency needs (must describe)
Emergency Need as referred by the
Department
Wrap-funds Allowable Amounts (per
State fiscal year)
Cannot exceed one (1) month’s Fair
Market Rent (FMR).
Cannot exceed one (1) month’s Fair
Market Rent (FMR).
Not to exceed Median Hotel rate from 3
motels in the area
Not to exceed 2 weeks unless approved
by the Department.
Not to exceed $500.00
Not to exceed $500.00
Not to exceed $500.00
Not to exceed $250.00
Not to exceed $250.00
Not to exceed $250.00
Not to exceed $250.00
Department discretion.
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PO Box 358, Fairfield, ME 04937 www.assistanceplus.com
1-800-781-0070 ext 426(207) 453-4708 ext 426Fax (207) 238-6302
Wrap-fund category and allowable amount –please check one per application
Security Deposit (must provide Security Deposit Request Form on page 8 of this application; not
to exceed one month’s Fair Market Rent as published by the U. S. Department of Housing and Urban
Development). Documented verification that State, Federal and local housing subsidies have been applied for
must accompany the application.
Rent Assist (must provide eviction notice or documentation of what is currently owed; not to
exceed one month’s Fair Market Rent as published by the U. S. Department of Housing and Urban
Development). Documented verification that State, Federal and local housing subsidies have been applied for
must accompany the application.
_______Temporary Housing in a motel: Criteria: all must be verified by consumer and/or 3rd party.
 Applicant is homeless, and/or Applicant has been denied access to homeless shelter.
 Applicant has behavioral and/or physical health issues which prohibits staying at a homeless shelter.
Any behavioral and/or physical health issues must be verified by a licensed professional.
 Agency to insure that they receive three (3) rates from area motels before approving application and
not to exceed median hotel rate for the area.
 Temporary housing may not exceed 2 weeks unless approved by the Department.
________Prescribed Medications (up to a 2 week supply)
1) Applicant must provide copy of the prescription signed by the prescriber and attach to Wrap-fund
application and
2) Applicant must provide a pharmacy bill and attach to the to Wrap-fund application.
________ Electric bill to maintain power in Applicant’s residence.
1) The Applicant must provide a copy of the disconnect notice and attach it to the Wrap-fund
application with the amount of payment required to prevent disconnection of power; and
2) The Applicant must provide a copy of an approved payment plan from power vendor for remaining
amount and attach to the Wrap-fund application.
_________Emergency fuel (one hundred (100) gallons, or one hundred (100) pounds lbs of propane, or one (1)
cord of wood)
Applicant must verify they have an appointment for fuel assistance and/or or must be actively applying for
State, Federal and town heating assistance programs and verify that it is the Applicant’s obligation to pay for
fuel under a lease/occupancy Agreement under the Applicant’s name.
_______Vision /Eye Care-not to exceed $250.00
Oral/Dental Care-not to exceed $250.00
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PO Box 358, Fairfield, ME 04937 www.assistanceplus.com
1-800-781-0070 ext 426(207) 453-4708 ext 426Fax (207) 238-6302
Transportation to include car repairs and transportation to access mainstream services-not to exceed
$250.00
_______ Other Emergency Need –must describe -not to exceed $250.00
_______ Other emergency need as referred by the Department
SECTION 17 ELIGIBILITY FORM ~ must be attached to Wrap-fund application.
To be completed for persons not already enrolled in Section 17/97 Services. A qualified professional
with one of the following credentials: MD, LCPC, LCSW, NP or Psychologist must complete this
form.
Part I. Applicant Information:
Page 1 of 2
Name: ____________________________________________________________________________________
Date of Birth: ______________________
Social Security Number:
____________________________
Part II. Specific Eligibility Requirements: Check all appropriate spaces that apply.
A client meets the specific eligibility requirements for covered services under Section 17 if:

A.
The person is a Class Member; (OR)

B.
The person is age eighteen (18) or older or is an emancipated minor:
-----AND----
1. Has a primary diagnosis on Axis I or Axis II of the multi-axial assessment system of the
current version of the Diagnostic and Statistical Manual of Mental Disorders, except that the
following diagnoses may not be primary diagnoses for purposes of this eligibility requirement:
a. Delirium, dementia, amnesic, and other cognitive disorders;
b. Mental disorders due to a general medical condition, including neurological conditions and
brain injuries;
c. Substance abuse or dependence;
d. Mental retardation;
e. Adjustment disorders;
f. V-codes; (or)
g. Antisocial personality disorders
-----AND----
2. AND Has a LOCUS score, as determined by staff certified for LOCUS assessment by DHHS
upon successful completion of prescribed LOCU S training, of seventeen (17) (Level III) or
greater, except that to be eligible for Community Rehabilitation Services (17.04-2) and ACT
(17.04-4) , the member must have a LOCUS score of twenty (20) (Level IV) or greater.
B.
An AMHI Consent Decree Class Member is eligible to receive Community Integration Services
(17.04-1) by virtue of class member status without meeting the eligibility requirements in
17.02-3(A).
C.
Eligible members who are eighteen (18) to twenty-one (21) years of age shall elect to receive
services as an adult or as a child. Those members electing services as an adult are eligible for
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PO Box 358, Fairfield, ME 04937 www.assistanceplus.com
1-800-781-0070 ext 426(207) 453-4708 ext 426Fax (207) 238-6302
services under this Section. Those electing services as a child may be eligible for services under
Chapter II, Section 65, Behavioral Health Services or Section 13 or both.
D.
The LOCUS must be administered, at least annually, or more frequently, if DHHS or its
Authorized Agent requires it. Members receiving services as of July 1, 2009 will have a LOCUS
administered at the time of their next annual review.
Page 2 of 2
Part III. DSM Diagnostic Classification: Diagnosis must be given by a qualified professional who is
licensed to make a mental health diagnosis.
AXIS I Classification #
Classification described
Date given:
AXIS II Classification #
Classification described
Date given:
AXIS III Classification #
Classification described
Date given:
AXIS IV Classification #
Classification described
Date given:
AXIS V (LOCUS Score) ____________
Part IV: Signatures and Certifications:
I certify that the information contained on this form is true and complete to the best of my knowledge and
belief. Intentionally submitting false or incomplete information is a crime.
_________________________________________________________
Clinician Signature and Credentials
Date
Print Name and Credentials
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PO Box 358, Fairfield, ME 04937 www.assistanceplus.com
1-800-781-0070 ext 426(207) 453-4708 ext 426Fax (207) 238-6302
SECURITY DEPOSIT AGREEMENT
LANDLORD:
TENANT:
_________________________________
__________________________________
Business Name
_________________________________
Business Address
_________________________________
Name
__________________________________
Address of Leased Premises
__________________________________
_________________________________
Tax ID or Social Security Numbered – Required
MONTHLY RENT:
$ _______________
TOTAL SECURITY DEPOSIT:
$ _______________
ASSISTANCE PLUS PORTION OF SECURITY DEPOSIT: $ _______________
In consideration of the Landlord’s leasing residential premises to Tenant as above indicated and the Landlord’s
following agreements concerning the security deposit, Assistance Plus is willing to pay the indicated Assistance Plus
portion of the security deposit. Landlord therefore agrees as follows.
The Assistance Plus portion of the security deposit shall in all respects be subject to the provisions of Maine law
governing residential security deposits, 14 MRSA §§ 6031 – 6039. Without limiting the foregoing, Landlord shall treat
the Assistance Plus portion of the security deposit as provided in 14 MRSA §§ 6035 and 6038 during the tenancy and
upon any termination of Landlord’s interest in the leased premises. Landlord shall promptly notify Assistance Plus in
writing of any termination of the lease or of Tenant’s habitation of the leased premises and shall return the Assistance
Plus portion of the security deposit to Assistance Plus within thirty (30) days after the date Tenant vacates the leased
premises, subject only to amounts Landlord may lawfully retain due to nonpayment of rent or physical damage to the
leased premises beyond normal wear and tear. In the event any amounts are so retained, Landlord shall within that
thirty (30) day period provide to Assistance Plus a written itemization of all amounts charged against the security
deposit together with payment of any remaining balance of the Assistance Plus portion of the security deposit after
application of the itemized retentions. In no event shall Assistance Plus be liable for any damages, costs or claims of any
kind under the lease either in excess of the Assistance Plus portion of the security deposit or arising from reasons other
than those which may lawfully be applied to retention of a security deposit for residential premises.
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PO Box 358, Fairfield, ME 04937 www.assistanceplus.com
1-800-781-0070 ext 426(207) 453-4708 ext 426Fax (207) 238-6302
AGREED BY LANDLORD:
By: _________________________________
Signature
_________________________________
Printed Name
Date: _______________________
Title : _______________________
Wrap-fund amount requested by Applicant $
8. Vendor Information: Vender information is required and must be completed. If an account number
is used by the vender that must be provided.
Payable to:
Mailing Address:
Phone:
Account # (if used):
Federal Tax ID Number:
Payments to vendors:
Wrap-funds payments are made only to vendors or businesses, with tax identification numbers within five (5)
business day of approval of the Wrap-fund application. A copy of the receipt for payment is must be received
from the same vendor or business that the Wrap-funds are being paid to. In no instance shall the Provider
make Wrap-funds payments or gift cards directly to the applicant, applicant’s case manager or applicant’s
family member or friend of the applicant.
Appeals:
A consumer who disagrees with the Committee’s decision may appeal the denial decision within 10 business
days of receipt of the decision in writing to: SAMHS Quality Management Specialist
41 Anthony Ave, SHS #11, Augusta, ME 04333-0011 (See Appendix 2)
Completed requests can be:
Emailed to: amichaud@assistanceplus.com please put WRAP in the subject line
Faxed to: 207-238-6302
Attn: Alisha Michaud
Or mail to : Assistance Plus WRAP Around Funds PO Box 358, Fairfield ME 04937
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PO Box 358, Fairfield, ME 04937 www.assistanceplus.com
1-800-781-0070 ext 426(207) 453-4708 ext 426Fax (207) 238-6302
OFFICE USE ONLY DO NOT WRITE BELOW THIS LINE
9. For each application, the Wrap-funds Committee must answer “YES” to the following five (5)
criteria for Wrap-funds to be approved:
Does the applicant verify that the need for
Wrap-funds is an emergency (an urgent need
requiring financial aid)?
Yes or No
Do Wrap-funds create a resolution to this
emergency need?
Has the applicant verified that they have
applied for all federal, state and community
subsidies?
Does the applicant’s current household budget
and income plan reflect that they are living
with in their financial means?
Does the Wrap-funds request fall under the
Wrap-fund emergency need and allowable
amount?
Yes or No
Yes or No
Yes or No
Yes or No
Committee Members:
Community Member Signature
Date
Applicant/Peer Signature
Date
Other Representative Signature
Date
Authorized By (Agency Representative)
Date
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PO Box 358, Fairfield, ME 04937 www.assistanceplus.com
1-800-781-0070 ext 426(207) 453-4708 ext 426Fax (207) 238-6302