Instructions for Attachments

In order to apply for the Housing Assistance Program, you will need to fill out this application and attach several supporting pieces of documentation. Please attach the following:  

1. Proof of brain injury as diagnosed by a medical professional

2. Proof of residency or future residency in our service area.

3. Proof of housing expense: bill, estimate, or receipt 

4. Proof of acute financial distress related to brain injury. Acceptable forms of proof are outlined below. Please attach at least one of the following:

• The prior year's tax forms with household AGI 

• Documentation showing all forms of income for the household. Examples include but are not limited to: paystubs, W-2s, SSI/SSDI awards, LTD awards, settlement awards, unemployment, and annuities. Include a signed written statement listing all forms of income and confirming that there are no other sources of income for the household. 

• Proof of Medicaid eligibility

• Bank statements documenting the household income for the past 30 days (can be used to demonstrate no household income). Include a signed written statement that the bank account details provided are the complete bank account details for the household.

If you answered "No" to any of the four questions above, your application will be denied. Please go back and attach the required documentation

If you answered “No” to the above question, skip to the next section. If you answered “Yes,” please attach additional proof of the recent change in financial situation related to a brain injury. Acceptable forms of proof are outlined below. Please attach at least one of the following: 

• A letter from a medical professional stating that the individual or another household member is unable to work or experiencing a reduction in hours due to a brain injury or caring for an individual with a brain injury

• Explanation of Benefits (or medical bills with a written and signed statement that the applicant is uninsured) showing proof of responsibility of payment of medical bills associated with the care and treatment of a brain injury beyond what they could reasonably be expected to pay given their financial situation

If you answered “Yes” to the above question, please skip to the next question. If you answered “No” to the above question, please sign and date a statement indicating why the funding you are requesting is essential to your housing situation and attach the statement to this application.

If you answered “Yes” to the above question, please skip to the next question. If you answered “No” to the above question, please attach evidence of ONE of the following: 

1. The move is associated with securing housing for an applicant who does not currently have housing.

2. The move is necessary due to no fault of the applicant, the new residence is more affordable than the previous residence, and the applicant is not making a significant sum off the sale of the previous residence which could feasibly be used to pay the requested amount

Application Attestation

I hereby affirm that all information provided in this application and attachments is current, complete, and accurate to the best of my knowledge. I am requesting this funding to help pay for housing costs due to acute financial distress related to my brain injury or the brain injury of someone I care for. 

I do hereby attest to understanding that should this application be approved, this money will ONLY be spent as requested. I am capable of receiving the money, spending it as intended, and providing proof that the funds have been spent as intended. I understand that if I fail to submit proof that the funds were used as intended, I will be ineligible for any financial assistance from the Brain Injury Alliance of NKY. I understand that filling out this application does not guarantee approval, and I may be asked to submit additional documentation before I am approved. I understand that I may not receive the full amount I am requesting. I understand that BIANK is not responsible for any of my personal expenses.