North Carolina Coalition to End Homelessness

PO Box 27692
Raleigh, NC 27611
Tel: 919-755-4393

Balance of State Participants

The form below asks for information about your agency's participation and activities in the Balance of State Continuum of Care.  This information is required to be included on the BoS's funding application to HUD.  Please answer all of the questions to the best of your ability.  If a question doesn't apply to you, please choose "None" or "Not applicable."
 
Thank you!   

Organization/Agency:*
Counties Served by Your Agency:*
Contact Person:*
Job Title:*
Mailing Address:*
City:*
State:*
Zip Code:*
Phone Number:*
Agency's Website:
Email Address:*
Organization's Type of Membership:*
Type of Organization (choices depend on answer above):*
Role in Balance of State CoC (check off all that apply):*
Subpopulations represented or served by the organization (check NO MORE THAN 2):*
If the organization provides services to homeless individuals/families, please list all that apply:*
Do your agency's case managers systematically assist clients in completing applications for mainstream benefits (such as Medicaid, SSI/SSDI, Work First/TANF, SNAP/Food Stamps, etc.)?*
If you are an agency that provides mainstream benefits (such as DSS), do you use a single application for four or more mainstream programs?*
If yes, what are the mainstream programs included on this application?
Does your program use HMIS as a way to screen for mainstream benefit eligibility?
If "Yes", indicate which mainstream benefit program eligibility screenings are completed using HMIS.
Does your agency supply transportation assistance to clients to attend mainstream benefits appointments, employment training, or jobs?*
Does your agency systematically follow up to ensure mainstream benefits are received?*

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