EMERGENCY FINANCIAL ASSISTANCE
(EFA) PROGRAM APPLICATION

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EFA Program Summary
The Emergency Financial Assistance (EFA) Program is funded through the District of Columbia Department of Health’s HIV/AIDS, Hepatitis, STD and TB Administration (HAHSTA) and is administered by Housing Counseling Services. The EFA Program provides financial assistance to persons who are HIV+ residing in the Washington D.C. Eligible Metropolitan Area (EMA) assessed to be in need of emergency food, first month's rent, back rent, utilities, moving, phone, and emergency medication assistance. Persons who are HIV+ may use this application to apply for emergency financial assistance through the EFA Program. Community case managers may also use this application to apply for emergency financial assistance on behalf of their clients.

Basic eligibility for the EFA Program application include:
  • The applicant must have a HIV+ diagnosis.
  • The applicant must live in the District of Columbia, the following counties in Maryland: Prince George’s, Montgomery, Charles, Calvert and Frederick, the following counties in Virginia: Arlington, Clarke, Culpeper, Fairfax, Fauquier, King George, Loudoun, Prince William, Spotsylvania, Stafford and Warren, and the following cities in Virginia: Alexanderia, Fairfax, Falls Church, Fredericksburg, Manassas, Manassas Park.
  • The applicant households’ income must not exceed 500% of the Federal Poverty Level (click here to see household income limits).
  • The applicant must have sought assistance from another community resource
  • The applicant has not exceeded their household’s EFA cap during the past 12 months.
HCS utilizes the D.C. Department of Health’s Centralized Eligibility System (CES) to verify eligibility for the EFA Program. The CES is used by Ryan White service providers in the D.C. metropolitan region to share client eligibility information and documents to help streamline the Ryan White eligibility determination process.

As a service provider, utilizing the CAREWARE system, HCS participates in the D.C. Eligible Metropolitan Area (EMA) Centralized Eligibility System (CES) in which Ryan White service providers in the D.C. metropolitan region can share client eligibility information and documents to help streamline the Ryan White eligibility determination process. The CAREWARE system is a computer software program specifically developed to help collect information and coordinate services for people living with specific health conditions.

A completed EFA application package will consist of the following documents:
  • Completed EFA Program Application
  • Picture ID for the HIV+ applicant
  • Signed Certification confirming applicant’s efforts to seek financial assistance from another community resource prior to applying for an EFA Program
  • Signed EFA Program Disclosures and Authorizations Statement
  • Signed Authorization of Representation/Release of Information/Consent for Services Statement
  • Signed DCEMA CAREWARE Centralized Eligibility System (CES) Statement
  • Signed EFA Program Agreement
Please be sure to provide all documents requested within the application and answer all questions in the application, as partial applications may be denied. PLEASE NOTE: HCS will verify information included in the application (for example: HIV status, residency, household income, etc.) through the CES. Please be aware that if HCS is unable to verify your eligibility for the EFA Program through the CES or through information on file with HCS, the applicant will need to submit documentation to HCS in a timely manner so that HCS may determine program eligibility.

If you have questions about the EFA Program, please email efaprogram@housingetc.org or call 202-667-2681.

Case Manager Information
Thank you for submitting this application on behalf of your client. Please complete this information about yourself and obtain Client Authorizations before continuing this form.




Obtain Client Authorizations and Disclosures
To obtain your client's authorizations and disclosures, please download this form here, have your client complete it, then upload the document below before moving forward in this form.






Primary Applicant Information
Applicant Name
Please pay special attention here to list your legal name in the order of First, Middle, then Last Name.




If applicant uses a name other than their legal name, please provide.

If anyone in the household is HIV positive, please list them as the primary applicant. Once you have done this, you will be able to continue with the application. If no one in the household is HIV positive, your household is not eligible for this program. Call with any questions at 202-667-2681.




If client does not have a social security number, please enter all zeroes
Contact Information








If client does not have an email address, please provide case manager's email



Demographic Information




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Primary Applicant Income
Please include all sources of income in the primary applicant's name only. Income sources for other household members should be added in a later section. Enter income one source at a time. To add another source, click "add another income source" below.



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Household Composition and Income

Include the applicant and any other individuals residing in the household full time
First Additional Household Member




If client does not have a social security number, please enter all zeroes


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First Additional Household Member Income
Please include all sources of income in this household member's name. Enter income one source at a time. To add another source, click "add another income source" below.



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Second Additional Household Member




If client does not have a social security number, please enter all zeroes


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Second Additional Household Member Income
Please include all sources of income in this household member's name. Enter income one source at a time. To add another source, click "add another income source" below.



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Third Additional Household Member




If client does not have a social security number, please enter all zeroes


Please select at least one of the values above.


Please select at least one of the values above.

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Third Additional Household Member Income
Please include all sources of income in this household member's name. Enter income one source at a time. To add another source, click "add another income source" below.



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Fourth Additional Household Member




If client does not have a social security number, please enter all zeroes


Please select at least one of the values above.


Please select at least one of the values above.

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Fourth Additional Household Member Income
Please include all sources of income in this household member's name. Enter income one source at a time. To add another source, click "add another income source" below.



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Fifth Additional Household Member




If client does not have a social security number, please enter all zeroes


Please select at least one of the values above.


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Fifth Additional Household Member Income
Please include all sources of income in this household member's name. Enter income one source at a time. To add another source, click "add another income source" below.



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Sixth Additional Household Member




If client does not have a social security number, please enter all zeroes


Please select at least one of the values above.


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Sixth Additional Household Member Income
Please include all sources of income in this household member's name. Enter income one source at a time. To add another source, click "add another income source" below.



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Seventh Additional Household Member




If client does not have a social security number, please enter all zeroes


Please select at least one of the values above.


Please select at least one of the values above.

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Seventh Additional Household Member Income
Please include all sources of income in this household member's name. Enter income one source at a time. To add another source, click "add another income source" below.



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Eighth Additional Household Member




If client does not have a social security number, please enter all zeroes


Please select at least one of the values above.


Please select at least one of the values above.

Please select at least one of the values above.



Eighth Additional Household Member Income
Please include all sources of income in this household member's name. Enter income one source at a time. To add another source, click "add another income source" below.



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Ninth Additional Household Member




If client does not have a social security number, please enter all zeroes


Please select at least one of the values above.


Please select at least one of the values above.

Please select at least one of the values above.



Ninth Additional Household Member Income
Please include all sources of income in this household member's name. Enter income one source at a time. To add another source, click "add another income source" below.



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Emergency Contact: Who should the program contact in case of emergency?

***If it is not possible to provide emergency contact information, type "N/A" for name and "000-000-0000" for phone number.***






If you are unable to check this box at least one household member needs additional data entered for their Race and/or Ethnicity above.
Choose Assistance Type(s)



Emergency Food Voucher
The maximum benefit for Emergency Food Voucher Assistance per application is $300 for an individual and $700 for a family with children dependents ($100 per dependent – max. 4 dependents). The 12 month benefit cap for individuals is $900 and for families is $2100. Applicants may access this benefit three times (3X) in a 12 month period, at intervals of at least 3 months.
Emergency Rental Assistance for Back Rent
Note: Applicant’s rent must be at least one month delinquent to be eligible for Past Due Rent assistance. Applicants residing in subsidized housing are ineligible for past due rent assistance.

The maximum benefit an applicant can receive, during a 12 month period, for the Emergency Rental Assistance service area is three times (3X) one month’s Fair Market Rent based on unit size.

Unit SizeEff.1BR2BR3BR4BR
2026 FMR (effective 10/1/2025)$1,953$2,015$2,246$2,835$3,332

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Landlord/Management Company Payment Information









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Emergency Utility Payment Assistance (Electric)
Note: The maximum benefit an applicant can receive, during a 12 month period, for the Emergency Utility Payments service area is $1500. Applicants residing in subsidized housing are ineligible for Emergency Utility Payment Assistance.



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Landlord/Management Company Payment Information








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Emergency Utility Payment Assistance (Gas/Oil)
Note: The maximum benefit an applicant can receive, during a 12 month period, for the Emergency Utility Payments service area is $1500. Applicants residing in subsidized housing are ineligible for Emergency Utility Payment Assistance.



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Landlord/Management Company Payment Information








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Emergency Utility Payment Assistance (Water)
Note: The maximum benefit an applicant can receive, during a 12 month period, for the Emergency Utility Payments service area is $1500. Applicants residing in subsidized housing are ineligible for Emergency Utility Payment Assistance.



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Landlord/Management Company Payment Information








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Emergency Rental Assistance for First Month's Rent

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Landlord/Management Company Payment Information









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Emergency Moving Assistance
If requesting Emergency Moving Assistance, complete this section. The maximum benefit an applicant can receive, during a 12 month period, for the Emergency Moving service area is $2000. Move must be within D.C. Eligible Metropolitan Area. This service may only be accessed once in a 12 month period.


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Address Moving To




Moving Company Payment Information









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Emergency Telephone Service Payment Assistance
The maximum benefit an applicant can receive during a 12 month period for the Emergency Telephone Service Payments service area is $300.



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Phone Company Payment Information









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Emergency Medication
Maximum assistance is $4000 per year and is only for medications not included in ADAP formulary. Applicants may access this benefit no more than two times (2X) in a 12 month period.




Household Expense Information
Enter expected expenses for next month for applicant’s household. This information will be used to help determine applicant’s need for financial assistance. If applicant does not pay toward the expense category, please enter “0”.

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Upload These Documents

We need a picture ID to verify your application.


Written documentation from a medical provider or laboratory reports denoting viral load.
Proof of Residency

Acceptable Documents:
  • Current lease or mortgage statement.
  • Deed settlement agreement.
  • Current driver's license.
  • Current voter registration card. 
  • Current notice of decision from Medicaid.
  • Fuel/utility bill (past 90 days).
  • Property tax bill or statement (past 60 days).
  • Rent receipt (past 90 days).
  • Pay stubs or bank statement with the name and address of the customer (past 30 days).
  • Letter from another government agency addressed to customer.
  • Active (unexpired) homeowner's or renter's insurance policy. 
  • DC Healthcare Alliance Proof of DC Residency form.
  • If homeless, a written statement from case manager or facility.

Proof of Income

Acceptable Documents:
  • Pay stubs for the past 30 days. The pay stub must show the year to date earnings, hours worked, all deductions, and the dates covered by the paystub.
  • A letter from the employer showing gross pay for the past 30 days, along with a copy of the most recent income tax return.
  • Business records for 3 months prior to application, indicating type of business, gross income, net income, and most recent year's individual income tax return. A statement from the customer projecting current annual income must be included. 
  • Copy of the tenant's lease showing customer as the landlord and a copy of their most recent income tax return.
  • SSD/SSI award letters, unemployment checks, social security checks, pension checks, etc. from the past 30 days.
  • Zero income attestation form and/or a letter from a supporting friend or family member stating how they support the customer.

If you are having difficulty uploading documentation, please submit your documents via email: efaprogram@housingetc.org or efax: 202-765-2763. If you submit this way, please call to confirm your documents were received to 202-667-2681.
Explanation of Financial Assistance Need




Stability Plan
Please identify the action(s) this household plans to take to prevent the need for future assistance. Please be specific in describing the actions this household will take. To add another action, click "Add Another Action" below.
Please identify the action(s) your household plans to take to prevent the need for future assistance. Please be specific in describing the actions your household will take.
Action Plan by Household Member



Action Plan by Household Member



Action Plan by Household Member



Additional Needs





Additional Needs





Referral Certification Form
It is expected that all other community sources of funding for financial assistance will be used prior to accessing Ryan White Emergency Financial Assistance. Applicants and case managers must complete the EFA Program Referral Certification Form and provide alternative referrals for each Ryan White Emergency Financial Assistance service area (excluding Moving Assistance, Phone Assistance and Emergency Medication Assistance service categories) in which they apply to verify efforts to access other community resources. List referral(s) below.
Emergency Food Assistance Referral



Emergency Rental Assistance Referral



Emergency Utility Assistance Referral



Client Disclosures & Authorizations

Authorization of Representation/Release of Information/Consent for Services/CAREWare
My signature authorizes HCS to release information (including HIV status and other protected health information) to housing and service providers operating within the HOPWA Housing System, Ryan White Services System, and DCDOH. This authorization may be revoked in writing. Revocations may be sent to HCS, Attn: EFA Program Manager, 2410 17th Street, NW Suite 100, Washington, DC 20009.

I understand that HCS will evaluate my application to determine eligibility for services available under the Emergency Financial Assistance Program Standards for the District of Columbia Eligible Metropolitan Area (EMA). HCS may need to speak with me or other parties to verify information contained within the submitted application. My signature confirms my consent for HCS to conduct activities necessary to fully evaluate my financial assistance application. I also understand that HCS, upon review of my financial assistance application, may request that I meet with a housing counselor to discuss my housing stability or to discuss concerns regarding the circumstances of my financial assistance request. 

My signature confirms that to the best of my knowledge and belief, the information contained within my application for financial assistance is true, complete, and accurate. I understand that if I have provided any false information within the application or during the application process, it may result in the denial of my application and may result in further investigation involving any intention to misuse government funds. 

My signature also confirms that I also understand that information I provide during the application process may be entered into CAREWare, which is an electronic health and social support services information system for Ryan White HIV/AIDS Program grant recipients and their providers. I understand that HCS staff may need to speak with me to collect additional information about my household for entry into CAREWare. I understand that failure to provide information requested by HCS for CAREWare may be grounds for the denial and closure of my application for housing assistance.
Housing Counseling Services Client Rights and Responsibilities
Housing Counseling Services, Inc. supports the rights of the client to express their concerns and opinions, actions and choices, and strives to ensure that each client is given respect, consideration, privacy and encouraged to participate in the development of their housing plans to achieve their housing, financial, and/or educational goals. These rights include the following:
  • The right to services, regardless of race, ethnicity, language, religious belief, sexual orientation, gender, age, marital status, health status, disability, and source of income.
  • The right to services delivered in a culturally competent manner.
  • The right to services without the threat of physical, sexual, psychological, and fiduciary harassment/abuse.
  • The right to information about the organization, its funders, and its services.
  • The right to access services easily and in a timely manner.
  • The right to be informed of available services/resources (ex. legal, financial, and mental health services) to address their current/future housing related needs.
  • The right to have the confidentiality of their client files maintained. Only where compelling ethical, moral or legal reasons (ex. child protection legislation) will information be shared.
  • The right to freely file a grievance, compliant, or appeal without retaliation Housing Counseling Services’ clients have the following responsibilities in accessing services.
  • The responsibility to treat HCS staff, volunteers, and other HCS clients with dignity and respect.
  • The responsibility to provide HCS staff with true and accurate information to ensure that the best possible service is provided.
  • The responsibility to assist in the development and participation in an agreed-upon service/housing plan to address their housing related need(s).
  • The responsibility to keep their scheduled appointments and to ensure prompt arrival. Clients should also provide timely notification of an appointment cancellation.
  • The responsibility to inform HCS of any changes in their contact information (name, address, phone, etc).
  • The responsibility to report any concerns about the delivery of HCS services, possible fraud or abuse.
Housing Counseling Services Client Grievance Procedures
The following procedures have been established to address client grievances with Housing Counseling Services (HCS) staff, policies, or procedures.  This document is provided to any client requesting it.
  1. If a client feels that HCS staff, procedures, or policies have prevented them from accessing services in a positive manner, they will be notified of these grievance procedures.
  2. HCS staff working with the grieving party shall provide the full name, phone number, email address, and address of their direct supervisor.  The client will be asked to contact that supervisor to discuss their concerns to seek an acceptable redress of their concerns.
  3. The supervisor will respond to the client’s concern directly, either in writing, in person, or through direct telephone conversation.
  4. If the grieving party still feels that the concern is not being addressed satisfactorily, the supervisor will provide the full name, email address and address of the Executive Director or Deputy Director (in the absence of the ED).
  5. The grieving party will be asked to write a letter outlining their grievance or concern and present it directly to the Executive Director or Deputy Director.
  6. The Executive Director or Deputy Director will offer to meet with the original staff member, supervisor, and client to discuss the grievance and attempt to resolve any concerns.
  7. After the meeting, the Executive Director or Deputy Director will write a letter responding to the written letter and/or issues outlined in the meeting.
  8. If the grieving party still feels that their concern is not being addressed satisfactorily, the Executive Director will provide the full name and mailing address of the President of the Board of Directors.
  9. The grieving party will be asked to forward a copy of their original written grievance, the HCS written response, and provide any additional information.
  10. The President of the HCS Board of Directors will review the written request for a grievance hearing.  The Board will directly hear grievances only as they concern HCS policy or complaints against the HCS Management.  Other complaints will be referred back to the Executive Director with recommendations for action.
EFA Food Voucher Agreement Statement
I understand that I am applying for the Ryan White Emergency Financial Assistance (EFA) food voucher. If approved I acknowledge that this voucher is intended for personal expenses related to my well-being and shall not be used to purchase alcohol, tobacco products, lottery tickets, or non-food items. Furthermore, I will not bargain, trade, nor exchange this card for other monetary value, products, and or services.
DCEMA CAREWARE Centralized Eligibility System Release of Information
Housing Counseling Services (HCS) is a Ryan White Program service provider for the D.C. Department of Health.  As a service provider, utilizing the CAREWARE system, HCS participates in the D.C. Eligible Metropolitan Area (EMA) Centralized Eligibility System (CES) in which Ryan White service providers in the D.C. metropolitan region can share client eligibility information and documents to help streamline the Ryan White eligibility determination process.   The CAREWARE system is a computer software program specifically developed to help collect information and coordinate services for people living with specific health conditions.

Your signature gives HCS authorization to share with other providers in D.C. Eligible Metropolitan Area (EMA) Centralized Eligibility System information and documentation you have submitted to HCS to verify your eligibility for Ryan White services, utilizing the CAREWARE system, including health status documentation, income documentation, residency documentation, and insurance documentation.   

Your authorization for utilizing your eligibility information/documentation submitted with this application for Ryan White EFA services will expire five years from the date of your signature.  You may revoke this authorization at any time by submitting a revocation request to HCS to the attention of the Program Manager for the EFA Program.  Furthermore, you understand that this Release of Information only applies to HCS and not to other providers within the EMA Centralized Eligibility System.  Information disclosed as a result of this Release of Information may be re-disclosed by other providers within the EMA Centralized Eligibility System and may no longer be protected by local, state, or federal privacy laws.  Your decision not to give HCS authorization to share your eligibility information/documentation with other providers through the D.C. Eligible Metropolitan Area Centralized Eligibility System will not impact your ability to receive assistance through the Emergency Financial Assistance Program. The expiration of this disclosure statement expires 365 days from the date of the customer's signature.
Disclosure/Authorization to Obtain Information Statement
I understand that Housing Counseling Services, Inc. (HCS) may need to contact individuals and/or agencies (including but not limited to landlords/property management companies, mortgage companies, utility companies, telephone companies, employers, government agencies, medical/support service providers, pharmacies, and attorneys) to acquire information and verify eligibility for its programs and to maintain contact with me.  My signature below serves as my consent for HCS to contact individuals, businesses, and/or service provider(s) necessary to document my eligibility and my need.

Further, as a participant in a program funded by the local and federal government, I understand that annual audits will be conducted to verify HCS’ compliance with local and federal regulations. My signature below also authorizes HCS to allow the review of my personal program file, including all verifications and documentation, by the HCS Organizational Auditor or Funding Agency Compliance Auditor/Monitor. All Auditors/Monitors are prohibited from disclosing any personal client information to any source. This authorization will remain in effect as long as an Organizational Auditor or Compliance Auditor/Monitor determines that the review of client files is necessary to complete federally mandated audits, reviews and report(s).
Upon clicking "Review Responses", you will need to review and sign this application before clicking submit. Once you have signed, you will be sent an email requesting that you authorize the signature by clicking on a secure link.

Case Manager Disclosures and Authorizations

Before proceeding to submission, carefully review the following statements and check the box below to indicate your full understanding and agreement.
Supervisor Support Disclosure




Case Manager Authorization
Upon clicking "Review Responses", you will need to review and sign this application before clicking submit. Once you have signed, you will be sent an email requesting that you authorize the signature by clicking on a secure link.
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