Welcome to Gulf Coast Community Services Association, Inc.

GCCSA exists to strengthen the educational, social, and economic well being of individuals

and families as they move toward independence and self-sufficiency.

ATTENTIONIf applying for services please

pick up an APPLICATION PACKET FOLDER from the

front desk.

Please make sure all documents are in

folder• Letter from CEO• GCCSA 2014 Application for

Service Packet• What do I need? worksheet• Referral Information Sheet

When Can I Submit My Completed

Application?

When Can I Submit My Completed

Application?In person at GCCSA Corporate

Office Monday- Wednesday (only)

9:00am-12:00pm 1:00pm- 4:00pm

How Do I Complete The 2014 Application

For Services?

Make sure you use blue or black ink only.

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 it jurisdiction.

Please ensure you have COPIES of all documents listed on page 2 of 8

from the 2014 application for services. GCCSA does not make

copies.

Please keep in mind GCCSA will make no more than THREE (3)

attempts to contact you via phone.

PLEASE PRINT LEGIBLY OTHERWISE YOUR

APPLICATION MAY BE CONSIDERED INCOMPLETE.

What Copies Are Needed?

List of Copies NeededEach Household Member:1. Social Security Card2. Picture Identification 3. Proof of Harris County Residency 4. Proof of Gross income for the past 30 days (If applicable)5. Proof of no income for the past 30 days (If applicable)

For a detailed list of acceptable documents, please refer to the WHAT DO I NEED worksheet.

Social Security Card

Picture Identification

Proof of Harris County Residency

Proof of Gross income for the past 30 days (If applicable)

Proof of no income for the past 30 days (If applicable)

Jane Doe

0.00

0.00

0.000.00

0.00

2013 2013

Part One – Household Information Guide

“In Care Of” refers to when a person doesn’t normally live at a certain address and does not receive mail there; in which case they would get mail “In Care Of” a person

that does get mail there.

Page 3 of 10

Why do I need to provide an alternate

contact?

Why do I need to provide an alternate contact?

An alternate contact is necessary in the event that you or your household members are unreachable.

Page 3 of 10

What if I don’t have a Social Security

Number?

What if I don’t have a Social Security number?

If you or someone in your household does not have a social security number please refer to the WHAT DO I NEED? worksheet.

Page 3 of 10

Part one- Household Information Guide (Cont.)

Please check ONLY ONE that best describes

your household.

Please check all that apply.

Page 3 of 10

Part Two Household Demographics Guide Date of birth

and age must be included

for all household members.

Please only check one box that best describes the relationship with the Head of Household (HH).

Gender as stated on

Birth Certificate.

Print Clearly

Page 4 of 10

Part Two Household Demographics Guide (Cont.)

Please only check one that applies to

your highest level of education.

Please select the race that is

stated on the birth certificate.

Check all that apply.

Page 4 of 10

Part Three- Income Sources Guide

Print Clearly • An example of Twice, Monthly income is when you are paid on set dates

in a month such as receiving a paycheck on the 15th & 30th of every month.

•An example of Bi-weekly income is receiving a paycheck every two weeks. In which case there are 26 pay periods in a year.

Please check all boxes that apply to your pay rate.

Page 5 of 10

What do I do if I have two jobs?

What do I do if I have two jobs?

Jane Doe

John Doe gets paid Bi-Weekly from his primary

job, and weekly from his weekend job mowing lawns.

Weekly

Page 5 of 10

John Doe

Along with his primary employment, John has selected Paid in Cash –

referring to his weekend job.

What do I do if I have NO INCOME?

What do I do if I have no income?

To Properly complete the above Income

Sources Table, please refer to the WHAT DO

I NEED? worksheet: PART 4 & 5.

For every applicant that has not received

any income for the past 30 days, please

check this box.

Page 5 of 10

Have you ever had a phone/in-house

interview with GCCSA?

Have you ever had a phone/in-house interview with GCCSA?

Page 7 of 10

Please check all boxes that apply to any service

you’ve received in the past.

Part Four – Referral Information Guide (Cont.)

Based on the information provided, we will be able to properly assess your needs.

What sort of hardship took place that led you to GCCSA?

Please specify so we know how best to assist you.

Page 6 of 8

Part Four – Referral Information Guide

(Continuation)

GCCSA requires your most reliable contact information and the time of day to contact you to schedule an appointment. It’s important to keep in mind that no more than THREE (3) call attempts will be made to contact you.

Before signing the Applicant Certification Page, make sure you

have done the following…Reviewed the “What do I need?” worksheet.Reviewed entire Application to ensure it is complete and correct.Made copies of all required documentation. GCCSA does not make copies of documents.Provided verification for all income sources for the past 30 days, this applies to all household members.Provided a stable contact phone number. Remember, GCCSA will make no more

than THREE (3) attempts to contact you via phone.

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 it jurisdiction.

It is important to read each statement CAREFULLY before placing your signature on the application certification page.

Applicant Certification

Visit our website at: www.GCCSA.org

“Got any questions?”

We’d like to hear what you have to say. Email us at: services@gccsa.org

Want to learn more about GCCSA and our

services?