In order for your application to be complete, copies of the following documents need to be included with the application.

Please ensure PDF documents are not password protected. Do not directly transfer PDFs from bank account or employment sites. Screenshots are acceptable.

To download and complete the Homeless Verification Form for upload, please click here.

This information will auto-populate from your answers in the 'Income Sources' portion of this form.

This tells you about your rights under the Minnesota Government Data Practices Act ("the Act"). This Act protects your privacy, but also lets us give information about you to others if a law requires it AND we tell you before we do it. The information below tells why and when we will ask for and give information about you.

What kind of information do we collect?
Generally, we only ask for two types of information from you - public information and private information. Public information is information about you that is available to anyone. Private Information is information about you that can be shared only if you give us your permission or if a law allows or requires us to share the information. We use summary information for reports that does not identify you or anyone else by name or other identifying information.

Why do we ask you for this information?
We may ask you for information so we can:
• Tell you from other persons by the same or similar name
• Decide if you can receive services from us and what or how much you can get
• Help you get financial or social services from other agencies
• Make reports, do research, audits, and evaluate our programs
• Collect money from government for help we give you

Do you have to answer the questions we ask? What will happen if you do not answer the questions we ask?
Generally, you do not have to give us information. However, if you do not give us the information, we may not be able to determine whether we can help you or get help for you from other agencies.

Whom shall we share the information about you?
We may give information about you to the following agencies if they need it to help you or help us help you. This does not mean we always share the information about you with these people.
• MN Dept of Human Services (OHS)
• Dept of Employment & Economic Development (DEED)
• MN Housing Finance Agency (MHFA)
• US Dept of Housing Urban Development (HUD)
• Clay or Douglas County HRA or local governments with whom we work with
• Anyone under contract with us or a government agency to provide services
• Other government agencies who have or may provide you with help
• Members of agencies of a local collaborative
• Guardian, conservator or a person who has power of attorney for you
• Anyone else the law says we can give the information

You have the right to copies of information we have about you.
• You may ask if we have any information about you.
• If we have information about you, you may ask for copies.
• You may give other people permission to see and have copies of private data about you.
• If you do not understand the information, you may ask to have it explained to you.


How do you appeal if you think information is not accurate or complete?
Your objection must be in writing and sent to: Missy Becker-Cook, Chief Executive Officer, 411 Industrial Park Blvd, Elbow Lake, MN 56531. You must tell us why the information is not accurate or complete. You may send your own explanation of the facts you disagree with. Your explanation will be attached any time that information is shared with another agency. For more information on how to do this, ask the staff person working with you.

If you have any questions about the information on this form, ask the staff person who is working with you.

My signature below affirms the data in this application is correct. I understand that:
• I have read the Tennessen Warning above;
• I may appeal the agency decisions about my application;
• I may have to prove my statements; and
• I may be prosecuted if I knowingly provide false information.

West Central MN Communities Action, Inc. will not discriminate. Our service will not discriminate against persons based on:
• Marital status
• Color
• Status with regard to public assistance
• Creed
• Disability
• Religion
• Sexual orientation
• National origin
• Age
• Gender
• Race
• Gender Identity
• Gender Expression
• Family Unit (Family is defined broadly and won’t separate if not a ‘traditional’ household)

If you need some type of assistance or accommodation in order to fully use our services, please tell any staff member. If you believe West Central MN Communities Action, Inc. has discriminated against you, or, if you believe we have not accommodated your need, you may file a complaint with:

Missy Becker-Cook, Chief Executive Officer
WCMCA, Inc.
411 Industrial Park Blvd Elbow Lake, MN 56531
Phone: 218.685.4486
Toll-free: 800.492.4805

We collect personal information about the people we serve and store this information in the CAP60 computer system.

WHY?
• To determine eligibility in our program and suggest other programs you may be eligible for.
• So we can report the number of individuals our agency has served and continue to receive funding for those services.
• So we can determine the services needed by individuals in our communities.

YOUR RIGHTS
• You have the right to see and obtain copies of the data maintained on you. (Unless we cannot give it because of certain legal proceedings).
• You have the right to be told the contents and meaning of the data.
• You have the right to challenge the accuracy and completeness of the data

To exercise these rights, contact, in writing:
Missy Becker-Cook, Chief Executive Officer
WCMCA, Inc.
411 Industrial Park Blvd
ElbowLake, MN 56531