CLIENT CHECKLIST HOMELESS PREVENTION FUNDING Requirements That Must Be Met Before An Application Will be Processed

Transcription

1 CLIENT CHECKLIST HOMELESS PREVENTION FUNDING Requirements That Must Be Met Before An Application Will be Processed Complete Application Forms for Individual or Family o Available online at -ORo Available at Tooele County Relief 38 South Main Street Meet with a case manager at Tooele County Relief Services. Once your application has been filled out, meet with a case manager at Tooele County Relief Services to obtain the referral letter which is required to complete your application packet. (Case managers are available Monday through Thursday, 10am to 5pm. If you are unable to meet during those hours, please call Karen Kuipers at to schedule at a different time. Homeless Certification. You must be homeless or have a 3-day eviction notice to be eligible for this funding. You can verify & document your situation by providing one of the following: o Agency Verification: If you are physically in your car, on the street or in a motel, please speak to a case manager at Relief Services about an agency verification form. o Eviction Notice. If you are currently renting, you must have an eviction notice (Notice to Vacate, signed by your landlord or other agent of the property owner.) o Affidavit of Housing Status. If you are staying with friends or family and planning on transitioning to your own rental unit to avoid homelessness, an affidavit of housing status must be completed by both you and the friend or family member who is asking you to leave. o Mortgage Statement or coupon reflecting status of account. Income Verification. All income for every member of the household must be documented. You can verify & document your income the last 30 days by providing any of the following: o Paystubs, DWS printout, SSI printout, ORS printout or a bank statement showing deposits. Picture ID for every adult, other ID for every child. Every person in the household who is considered to determine eligibility must provide the following: o Adults: Picture ID i.e. drivers license, state ID, etc. ANDo EVERY household member: social security cards or birth certificates (check with case manager for alternate proof of identity & citizenship if necessary). HMIS Informed Consent Forms. Every adult in the household must sign their own consent form. Copy of Lease or Mortgage Statement. You must verify that you have a written agreement with the landlord of your current or proposed rental unit. At a minimum, a lease agreement must be signed by one adult member of your household and a representative of the property owner. W-9 Form for Landlord OR- Mortgage Coupon. Your landlord must sign and complete a W-9 form. They might not be comfortable giving the tax form to you to return, but they can fax it to Relief Services, mail it OR it. Applications will NOT be processed until a W-9 is received. Allow 10 business days for review and processing once the application has been submitted to the Housing Authority! Budget Worksheet. You must show a sustainability plan, which will be reflected on your budget. Please have information on all of your expenses available when your case manager meets with you.

2 Last Name of Head of Household First Name of Head of Household Md. Initial Family ID Ο Full SSN Reported Ο Full DOB Reported Ο Partial SSN Reported Ο Partial/Approximate DOB Reported SSN DOB Race mark all that apply Gender Associated with a family? Ο Asian Ο Male Ο Yes Ο No Ο Black/African American Ο Female Relation to Head of Household Ο Native Hawaiian/Pacific Islander Ο Transgendered Male to Female Ο Self Ο Dep. Child Ο Other Fm. Ο White Ο Transgendered Female to Male Ο Parent Ο Grandparent Ο Other Non Ο Son Ο Guardian Family Ο Daughter Ο Spouse Ο Other CT Veteran: Ο Yes Disabling Condition: Ο Yes Ο No Ο No Address City State Zip Code

3 Family Members Member 1 Last Name First Name Md. Initial Ο Full SSN Reported Ο Full DOB Reported Ο Partial SSN Reported Ο Partial/Approximate DOB Reported SSN DOB Race mark all that apply Gender Relation to Head of Household Ο Asian Ο Male Ο Self Ο Dep. Child Ο Other Fm. Ο Black/African American Ο Female Ο Parent Ο Grandparent Ο Other Non Ο Native Hawaiian/Pacific Islander Ο Transgendered Male to Female Ο Son Ο Guardian Family Ο White Ο Transgendered Female to Male Ο Daughter Ο Spouse Ο Other CT Veteran: Ο Yes Disabling Condition: Ο Yes Ο No Ο No Member 2 Last Name First Name Md. Initial Ο Full SSN Reported Ο Full DOB Reported Ο Partial SSN Reported Ο Partial/Approximate DOB Reported SSN DOB Race mark all that apply Gender Relation to Head of Household Ο Asian Ο Male Ο Self Ο Dep. Child Ο Other Fm. Ο Black/African American Ο Female Ο Parent Ο Grandparent Ο Other Non Ο Native Hawaiian/Pacific Islander Ο Transgendered Male to Female Ο Son Ο Guardian Family Ο White Ο Transgendered Female to Male Ο Daughter Ο Spouse Ο Other CT Veteran: Ο Yes Disabling Condition: Ο Yes Ο No Ο No

4 Family Members (Continued) Member 3 Last Name First Name Md. Initial Ο Full SSN Reported Ο Full DOB Reported Ο Partial SSN Reported Ο Partial/Approximate DOB Reported SSN DOB Race mark all that apply Gender Relation to Head of Household Ο Asian Ο Male Ο Self Ο Dep. Child Ο Other Fm. Ο Black/African American Ο Female Ο Parent Ο Grandparent Ο Other Non Ο Native Hawaiian/Pacific Islander Ο Transgendered Male to Female Ο Son Ο Guardian Family Ο White Ο Transgendered Female to Male Ο Daughter Ο Spouse Ο Other CT Veteran: Ο Yes Disabling Condition: Ο Yes Ο No Ο No Member 4 Last Name First Name Md. Initial Ο Full SSN Reported Ο Full DOB Reported Ο Partial SSN Reported Ο Partial/Approximate DOB Reported SSN DOB Race mark all that apply Gender Relation to Head of Household Ο Asian Ο Male Ο Self Ο Dep. Child Ο Other Fm. Ο Black/African American Ο Female Ο Parent Ο Grandparent Ο Other Non Ο Native Hawaiian/Pacific Islander Ο Transgendered Male to Female Ο Son Ο Guardian Family Ο White Ο Transgendered Female to Male Ο Daughter Ο Spouse Ο Other CT Veteran: Ο Yes Disabling Condition: Ο Yes Ο No Ο No

5 Family Members (Continued) Member 5 Last Name First Name Md. Initial Ο Full SSN Reported Ο Full DOB Reported Ο Partial SSN Reported Ο Partial/Approximate DOB Reported SSN DOB Race mark all that apply Gender Relation to Head of Household Ο Asian Ο Male Ο Self Ο Dep. Child Ο Other Fm. Ο Black/African American Ο Female Ο Parent Ο Grandparent Ο Other Non Ο Native Hawaiian/Pacific Islander Ο Transgendered Male to Female Ο Son Ο Guardian Family Ο White Ο Transgendered Female to Male Ο Daughter Ο Spouse Ο Other CT Veteran: Ο Yes Disabling Condition: Ο Yes Ο No Ο No Area Median Income $ Date of Assessment Annual Household Income Family Size County (Area) ($ ) Counties AMI for Family size

6 HEAD of HOUSEHOLD Assessment Date of Enrollment Program Name Zip code Prior Residence Zip Code Quality Ο Emergency Shelter Ο TH for Homeless Ο Perm. Hsg for Homeless Ο Full Zip Code Ο Psychiatric Hosp./Facility Ο Sub. Abuse detox cntr. Ο Hospital (non-psychiatric) Ο Jail/Prison/Juvenile Det. Ο Stay/Live with Family Ο Stay/live with Friend Ο Hotel/Motel non-voucher Ο Foster Care/Group Hm. Ο Place not meant for Hab. Ο Other Ο Safe Haven Ο Rental, VASH Subsidy Hsg. Status at Entry Ο Rental, other (non-vash) Sub. Ο Owned, with subsidy Ο Rental, no subsidy Ο Literally Homeless Ο Owned, no subsidy Ο Unstably Housed/ At-risk of loosing hsg. Length of Stay prior residence) Ο Imminently losing their Ο One week or less Ο More than 1 week, less than 1 mth. housing Ο 1-3 months Ο More than 3 months, less than 1 year Ο Literally Homeless Ο One year or longer Ο Stably housed - Rent Ο Stably housed - Own Ο Yes Ο No Does Client receive income from employment or other sources? Does Client receive non-cash benefits? Ο Yes Ο No (If yes to either question continue to fill out the INCOME and NON-CASH BENEFITS section) Income (complete all sources of monthly income) Income Type Description Amount Ο Earned Income (i.e. employment income) Ο Unemployment Insurance Ο Supplemental Security Income (SSI) Ο Social Security Disability Income (SSDI) Ο Veteran s Disability Payment Ο Private Disability Insurance Ο Worker s Compensation Ο Temp. Assistance for Needy Family (TANF) Ο General Assistance Ο Retirement Income from Social Security Ο Veteran s Pension Ο Other Pension Ο Child Support Ο Alimony/Other Spousal Support Ο Other Income

7 Non-Cash Benefits (complete all sources of monthly income) Income Type Ο Supplemental Nut. Assistance (FOOD STAMPS) Ο MEDICAID Ο MEDICARE Ο State CHIP Ο WIC Ο Veteran s Admin. Medical Services Ο TANF Child Care Services Ο TANF Transportation Services Ο Other TANF Funded Services Ο Sec. 8, Public Housing, or other Rental ongoing rental assistance Ο Other Source Ο Temporary Rental Assistance Description Employment Ο Yes Ο No Is Client Employed? (If yes How many hours worked last week? ) (If Yes - Employment Tenure: Ο Permanent Ο Temporary Ο Seasonal ) Is Client looking for Work (additional employment/hours)? Ο Yes Ο No *GRANT PROGRAM

8 House Hold Members Assessment Name of Family Member: ** Conduct for Each member of the House Hold** Date of Enrollment Program Name Zip code Prior Residence Zip Code Quality Ο Emergency Shelter Ο TH for Homeless Ο Perm. Hsg for Homeless Ο Full Zip Code Ο Psychiatric Hosp./Facility Ο Sub. Abuse detox cntr. Ο Hospital (non-psychiatric) Ο Jail/Prison/Juvenile Det. Ο Stay/Live with Family Ο Stay/live with Friend Ο Hotel/Motel non-voucher Ο Foster Care/Group Hm. Ο Place not meant for Hab. Ο Other Ο Safe Haven Ο Rental, VASH Subsidy Hsg. Status at Entry Ο Rental, other (non-vash) Sub. Ο Owned, with subsidy Ο Rental, no subsidy Ο Literally Homeless Ο Owned, no subsidy Ο Unstably Housed/ At-risk of loosing hsg. Length of Stay prior residence) Ο Imminently losing their Ο One week or less Ο More than 1 week, less than 1 mth. housing Ο 1-3 months Ο More than 3 months, less than 1 year Ο Literally Homeless Ο One year or longer Ο Stably housed - Rent Ο Stably housed - Own Ο Yes Ο No Does Client receive income from employment or other sources? Does Client receive non-cash benefits? Ο Yes Ο No (If yes to either question continue to fill out the INCOME and NON-CASH BENEFITS section) Income (complete all sources of monthly income) Income Type Description Amount Ο Earned Income (i.e. employment income) Ο Unemployment Insurance Ο Supplemental Security Income (SSI) Ο Social Security Disability Income (SSDI) Ο Veteran s Disability Payment Ο Private Disability Insurance Ο Worker s Compensation Ο Temp. Assistance for Needy Family (TANF) Ο General Assistance Ο Retirement Income from Social Security Ο Veteran s Pension Ο Other Pension Ο Child Support Ο Alimony/Other Spousal Support Ο Other Income

9 Non-Cash Benefits (complete all sources of monthly income) Income Type Ο Supplemental Nut. Assistance (FOOD STAMPS) Ο MEDICAID Ο MEDICARE Ο State CHIP Ο WIC Ο Veteran s Admin. Medical Services Ο TANF Child Care Services Ο TANF Transportation Services Ο Other TANF Funded Services Ο Sec. 8, Public Housing, or other Rental ongoing rental assistance Ο Other Source Ο Temporary Rental Assistance Description Employment Ο Yes Ο No Is Client Employed? (If yes How many hours worked last week? ) (If Yes - Employment Tenure: Ο Permanent Ο Temporary Ο Seasonal ) Is Client looking for Work (additional employment/hours)? Ο Yes Ο No *GRANT PROGRAM Relation to Head of Household Ο Parent Ο Dependent Child Ο Spouse Ο Other Caretaker Ο Son Ο Grandparent Ο Other Family Member Ο Daughter Ο Guardian Ο Other Non-Family

10 Individual Intake & Assessment Form - Rapid Re-Housing and Homeless Prevention Programs Last Name First Name Md. Initial Family ID Ο Full SSN Reported Ο Full DOB Reported Ο Partial SSN Reported Ο Partial/Approximate DOB Reported SSN DOB Race mark all that apply Gender Associated with a family? Ο Asian Ο Male Ο Yes Ο No Ο Black/African American Ο Female Relation to Head of Household Ο Native Hawaiian/Pacific Islander Ο Transgendered Male to Female Ο Self Ο Dep. Child Ο Other Fm. Ο White Ο Transgendered Female to Male Ο Parent Ο Grandparent Ο Other Non Ο Son Ο Guardian Family Ο Daughter Ο Spouse Ο Other CT Veteran: Ο Yes Disabling Condition: Ο Yes Ο No Ο No Address City State Zip Code Area Median Income $ Date of Assessment Annual Household Income Family Size County (Area) ($ ) Counties AMI for Family size INDIVIDUAL INTAKE & ASSESSMENT FORM HPRP Workflow

11 Individual Intake & Assessment Form - Rapid Re-Housing and Homeless Prevention Programs Assessment Date of Enrollment Program Name Zip code Prior Residence Zip Code Quality Ο Emergency Shelter Ο TH for Homeless Ο Perm. Hsg for Homeless Ο Full Zip Code Ο Psychiatric Hosp./Facility Ο Sub. Abuse detox cntr. Ο Hospital (non-psychiatric) Ο Jail/Prison/Juvenile Det. Ο Stay/Live with Family Ο Stay/live with Friend Ο Hotel/Motel non-voucher Ο Foster Care/Group Hm. Ο Place not meant for Hab. Ο Other Ο Safe Haven Ο Rental, VASH Subsidy Hsg. Status at Entry Ο Rental, other (non-vash) Sub. Ο Owned, with subsidy Ο Rental, no subsidy Ο Literally Homeless Ο Owned, no subsidy Ο Unstably Housed/ At-risk of loosing hsg. Length of Stay (@ prior residence) Ο Imminently losing their Ο One week or less Ο More than 1 week, less than 1 mth. housing Ο 1-3 months Ο More than 3 months, less than 1 year Ο Literally Homeless Ο One year or longer Ο Stably housed - Rent Ο Stably housed - Own Ο Yes Ο No Does Client receive income from employment or other sources? Does Client receive non-cash benefits? Ο Yes Ο No (If yes to either question continue to fill out the INCOME and NON-CASH BENEFITS section) Income (complete all sources of monthly income) Income Type Description Amount Ο Earned Income (i.e. employment income) Ο Unemployment Insurance Ο Supplemental Security Income (SSI) Ο Social Security Disability Income (SSDI) Ο Veteran s Disability Payment Ο Private Disability Insurance Ο Worker s Compensation Ο Temp. Assistance for Needy Family (TANF) Ο General Assistance Ο Retirement Income from Social Security Ο Veteran s Pension Ο Other Pension Ο Child Support Ο Alimony/Other Spousal Support Ο Other Income INDIVIDUAL INTAKE & ASSESSMENT FORM HPRP Workflow

12 Individual Intake & Assessment Form - Rapid Re-Housing and Homeless Prevention Programs Non-Cash Benefits (complete all sources of monthly income) Income Type Ο Supplemental Nut. Assistance (FOOD STAMPS) Ο MEDICAID Ο MEDICARE Ο State CHIP Ο WIC Ο Veteran s Admin. Medical Services Ο TANF Child Care Services Ο TANF Transportation Services Ο Other TANF Funded Services Ο Sec. 8, Public Housing, or other Rental ongoing rental assistance Ο Other Source Ο Temporary Rental Assistance Description *GRANT PROGRAM INDIVIDUAL INTAKE & ASSESSMENT FORM HPRP Workflow

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