SHELTER PLUS CARE REFERRAL/APPLICATION PACKET

Transcription

1 SHELTER PLUS CARE REFERRAL/APPLICATION PACKET Applicant s Name: Date: Referral Source: Referral Source Contact Person: Contact Phone #: Eastpointe is committed to delivering a continuum of services to individuals that have been traditionally hard to reach- homeless persons with disabilities such as serious mental illness, chronic substance abuse, and/or AIDS and related diseases. These services are designed to provide individuals the opportunity to increase housing stability, increase skills and/or income, and obtain greater self-sufficiency

2 SHELTER PLUS CARE REFERRAL PACKET CHECKLIST Cover Sheet Page 1 Checklist Page 2 Introduction Page 3-4 Application Page 5-8 Questionnaire Page 9 Verification of Homelessness Page Verification of Chronically Homelessness Detached Template Verification of Disability Page 12 Asset Verification Page 13 Verification of Employment Income Page 14 Verification of Unemployment Benefit Income Page 15 Verification of Social Security Data Page 16 Verification of Medical Expense Page 17 Copy of Birth Certificate (for each child) Copy of Social Security Card (for applicant and each child) Copy of valid driver s license of state issued identification card (for applicant) Copy of Homelessness Verification Letter on Company Letterhead (See instructions Sheet) Copy of Current Person Centered Plan Copy of Mental Health Evaluation/Assessment (must have been completed within last 12 months of submission of application

3 Introduction Thank you for your interest in Eastpointe s Shelter Plus Care Program. The Shelter Plus Care Program is a HUD funded subsidized housing program that assists homeless people with disabilities. In order to participate in the Shelter Plus Care Program, the client must meet the HUD definition of homelessness, have a disability documented by a Licensed Psychologist or Licensed Psychiatrist, and participate in supportive services at program entry. The overall goals of the Shelter Plus Care Program are: 1) to increase housing stability; 2) to increase skills and/or income; and 3) to gain greater self-sufficiency. A supportive services agency must have the skills and experience working with homeless and disabled clients to provide the support necessary to keep participants housed. In particular, they must offer intensive case management and ongoing supportive services. Providing the level of service required to keep participants in their housing is essential to a successful program. If the supportive services agency meets the above criteria, the referring case manager must receive the Shelter Plus Care Training within the open application timeframe in order of applications to be considered. For more information or questions please contact LaTasha McNair, Community Housing Manager, at or Ltmcnair@eastpointe.net. Please complete and provide the following upon submission of your application: 1. Referral/Application Form (faxed applications will not be accepted) 2. Homeless Eligibility Documentation Form (also need to attach a statement on company letterhead verifying chronic homelessness, signed and dated by either the case manager; emergency shelter staff; or transitional housing program which must also be accompanied with statement from case manager on company letter head, signed and dated. 3. Disability, Handicap, or Mental Illness Verification Form (can only be signed by a Licensed Psychiatrist or Licensed Psychologist) 4. Asset Verification Form 5. Employment Income Verification Form (If applicable, also submit proof of employment income, i.e. paycheck stub no older than 30 days) 6. Unemployment Benefit Income Verification Form (If applicable, also submit proof of unemployment benefit, i.e. documentation from Employment Security Commission 7. Social Security Data Verification Form (If applicable, also submit proof of Social Security benefit, i.e. most recent award letter from Social Security Administration)

4 8. Medical Expense Verification Form (If applicable, also submit receipts for any out of pocket medical expenses, i.e. co-pays for medical services and prescriptions 9. Authorization for Release of Information Forms 10. Identification, i.e. social security card and valid driver s license or ID card for adult household members (Copy) 11. Social Security Cards and Birth Certificates for all Members of Household under 18 years of age (Copy) 12. Person Centered Plan (Copy) Please return all information by mail to: Eastpointe, Attn: Housing Department, to the address listed below. Faxed and ed applications will not be accepted. Once we have received and reviewed the items listed above, the applicant will be scheduled an interview with the Shelter Plus Care Housing Staff to determine eligibility. APPLICATIONS WILL BE RETURNED AS INCOMPLETE IF ALL REQUESTED DOCUMENTS ARE NOT INCLUDED. Wilson and Greene Counties: 500 Nash Medical Arts Mall Rocky Mt, NC Robeson, Bladen, Columbus, and Scotland Counties: 450 County Club Road Lumberton, NC For more information, please contact LaTasha McNair at Again, thank you for interest in Eastpointe s Shelter Plus Care Program.

5 EASTPOINTE HUMAN SERVICES SHELTER PLUS CARE REFERRAL/APPLICATION SHELTER PLUS CARE SUBSIDY (TO QUALIFY FOR THIS PROGRAM, THE APPLICANT MUST MEET HUD DEFINITION FOR HOMELESS, HAVE A CERTIFIED DISABILITY THAT IMPAIRS THE APPLICANT S ABILITY TO WORK, AND MEET VERY LOW INCOME GUIDELINES). PLEASE ATTACH THE FOLLOWING DOCUMENTS: VERIFICATION FORMS FOR ALL INCOME AND ACCOUNTS LISTED BELOW VERIFICATION OF HOMELESSNESS AS ESTABLISHED BY ATTACHED HUD CERTIFICATION GUIDE SERVICE/TREATMENT PLAN (MUST INCLUDE HOUSING PROBLEMS/NEEDS AND GOALS) NOTE: IF THE APPLICANT IS IN REMISSION OR HAS A RECENT SUBSTANCE ABUSE PROBLEM, SHELTER PLUS CARE APPLICANTS MUST HAVE 60 DAYS OF CLEAN TIME DEMONSTRATED BY RANDOM DRUG SCREENS. Date: Name: Date of Birth: SS#: Race: Marital Status: Gender: Current Address: City: State: ZIP Code: Telephone #: Are you a veteran? Legal Guardian? If yes, list name of guardian: Diagnosis: Axis I: Axis II: Axis III: Axis IV: Axis V:

6 Agency: REFERRING AGENCY INFORMATION Case Support Staff: Office Phone: Fax: Address: City: State: ZIP Code: PREVIOUS LIVING SITUATION 1) Estimate number of times candidate has been homeless within the past (3) years: 2) Prior living situation one (1) day prior to submission of Shelter Plus Care Application: In places not meant for human habitation, such as cars, parks, sidewalks, abandoned Buildings (on the street)-must have written certification from Case Support Staff on Company letterhead Emergency Shelter-must have a letter from shelter Transitional or supportive housing program-must have a letter from the program stating Homeless prior to admission in their program 3) Has applicant ever resided in a Section 8 unit or property? yes no If yes, from what dates did the participant reside in a Section 8 unit or property? If yes, why did the participant leave the Section 8 unit or property? If yes, did the applicant leave the Section 8 unit or property owing Section any money for damages, court costs, or back rent?

7 CURRENT LIVING SITUATION 1) Is candidate currently homeless? YES NO 2) At application submission, client has been homeless: Less than 1 month At least 1 month but less than 6 months At least 6 months but less than 1 year Chronically Homeless-continuously for 1 year OR has had at least (4) episodes of homelessness in the past 3 years. HOUSEHOLD COMPOSITION Name/Relationship Date of Birth Gender Social Security# SOCIAL HISTORY Give brief Social History (Include events that led to applicant being homeless and current living situation): Service Received SUPPORT SERVICES Name of Provider Average Frequency of Contact When did services begin?

8 INCOME INFORMATION List all sources of income, the amount of the annual income of members listed above and attach verification forms for all income listed such as employment income before any payroll deductions, SSI, SSDI, annuities, insurance policies, retirement funds, pensions, death benefits, lump sum payments for delayed start of a periodic payment such as SSDI, payments in lieu of earnings such as unemployment and disability compensation, worker s compensation, severance pay; welfare assistance (welfare or other payments to families or individuals, based on need, that are made under programs funded, separately or jointly, by Federal, State or local governments, e.g., Aid to Families with Dependent Children, Supplemental Security Income, and general assistance available through state welfare programs such as, TANF), alimony, child support payments, regular contributions or gifts received from persons not residing in the dwelling; other (specify) Name Source/Type of Income Monthly Amount ASSETS INFORMATION List the checking and savings account of each member listed above and attach verification forms for all accounts listed). Name Bank Account # Balance As the applicant for Shelter Plus Care housing, I certify that all of the above information is true, and I authorize the undersigned program representative to verify all information in this application. I understand that providing false information on this application may result in denial or termination of assistance. Signature of Person completing form (if not applicant): Relationship to applicant: Signature of Applicant: Date: Date:

9 QUESTIONNAIRE (All questions MUST be answered or your application will NOT be processed). 1. Do you plan to have anyone who is not listed above live with you in the future? YES NO 2. Are any other household members disabled, including children? YES NO 3. Have you ever lived in federally subsidized housing such as Section 8? YES NO 4. Are you a U.S. veteran? YES NO 5. Are you a Domestic violence victim/survivor? YES NO 6. Have you lived in an adult care home? YES NO If yes, Adult Care Home you lived in most recently 7. Are you an ex-offender? YES NO 8. What is the highest level of education you have attained? 9. Do you receive any of the following Non-Cash Benefits (Please check ALL that apply): Supplemental Nutritional Assistance Program MEDICAID Health Insurance MEDICARE Health Insurance State Children's Health Insurance WIC VA Medical Services TANF Child Care Services TANF Transportation Services Other TANF-Funded Services Temporary Rental Assistance Section 8, Public Housing, Rental Assistance 10. Does any of your children receive any of the following Non-Cash Benefits (Please check ALL that apply): Supplemental Nutritional Assistance Program MEDICAID Health Insurance MEDICARE Health Insurance State Children's Health Insurance WIC VA Medical Services TANF Child Care Services TANF Transportation Services Other TANF-Funded Services Temporary Rental Assistance Section 8, Public Housing, Rental Assistance

10 SHELTER PLUS CARE VERIFICATION OF HOMELESSNESS/CHRONIC HOMELESSNESS Applicant: Eligibility for Shelter Plus Care is limited to persons who are homeless and disabled as defined by HUD regulations 24 CFR Indicate which situation described below best describes the living situation of the applicant and attach to this form required documentation. A place not meant for human habitation, such as cars, parks, sidewalks, abandoned buildings (on street). Certification form signed by outreach worker or service worker verifying that the person of family is homeless. This could include a letter or certification form signed by outreach worker or service provider from another organization that can verify that the person or family was in fact homeless as described in the above definition, or a written statement prepared by the participant about the participant s previous living place (if unable to verify by outreach worker or service provider). Have participant sign and date. An emergency shelter. Referral agency certification that participant has been residing at the emergency shelter (on agency letterhead/shelter, signed, and dated). A transitional or supportive housing program for homeless persons who originally came from the streets or emergency shelters (make sure you have evidence that the person came from the street or emergency shelters situation). Certification (on agency letterhead, signed, and dated) if the participant is residing at the transitional housing facility as well as written verification that the participant was living on the streets or an emergency shelter prior to living in the transitional housing facility (see above for required documentation). ANSWERING YES TO A QUESTION ON AN APPLICATION ASKING IF A PERSON IS HOMELESS IS NOT SUFFICIENT EVIDENCE OF HOMELESSNESS. CHRONICALLY HOMELESS PERSON: An unaccompanied homeless individual with a disabling condition who has either been continuously homeless for a year or more OR has had at least 4 episodes of homelessness in the past (3) YEARS. To be considered chronically homeless, a person must have been on the streets or in an emergency shelter (i.e., not transitional housing) during these stays. **NOTE: You will be expected to prove that the chronically homeless person has been continuously homeless for a year or more OR that the person has had the 4 episodes of homelessness in the past three (3) years. This documentation could be a certification (on letterhead) form an emergency shelter for the last year as documented by outreach efforts or been a resident in their shelter at least 4 times during the past three years. **Also, you should have documentation related to the client s disability; you must have some narrative documentation related to the disabling condition that most likely results in their homeless/chronic homelessness.

11 I certify that I have made every effort to confirm that: (Applicant Name) is homeless. Documentation to support this statement is attached. Signature/Title Agency: Date:

12 Shelter Plus Care Program Verification of Disability, Handicap or Mental Illness Project Name: Shelter Plus Care Program Print Tenant/Applicant Name: The person named above is a tenant/applicant for a dwelling unit in the above referenced project. Federal law requires us to obtain verification of disability or handicap for each tenant/applicant to determine his/her eligibility for occupancy in the project. For the purpose of qualifying for occupancy in the project, the tenant/applicant must meet a three-part test; (a) as a result of his/her disability, the need for treatment is expected to be of a long, continued and indefinite duration, (b) the disability substantially impedes his/her ability to live independently; and (c) is of such nature that the disability could be improved by more suitable housing conditions. If the participant is disabled by chronic problems with alcohol and/or drugs, the disability must meet the following criteria: Problematic use/abuse of alcohol and/or drugs that (1) has occurred for at least twelve months and (2) has caused serious difficulties in interpersonal relationships as evidenced by disruptions in employment, loss of housing, and/or loss of role in family structures or other important relationships. The information requested will be kept in strict confidence. If you have any questions, please contact our office at the number below. Thank you for your cooperation in completing and returning this form as soon as possible. I authorize to release all information concerning my disability. (Name of Doctor, Agency or Institution) Signature of Tenant/Applicant CONFIDENTIAL INFORMATION: PSYCHIATRIST OR LICENSED PSYCHOLOGIST ONLY In my opinion, the above referenced tenant/applicant is or is not disabled as defined above. PLEASE CIRCLE ONE OR MORE: Disability Code: 1=Seriously Mentally Ill 2=Chronic Substance Abuser 3=SMI and CSA (1&2) 4=Persons with AIDS 5=Other I, (Licensed Psychiatrist/Psychologist), confirm that (Tenant/Applicant), does in fact meet the three-part test and qualifies under the disability code on this day, month, and year. Signature: Telephone Number: Address:

13 Project Name: Shelter Plus Care Program Shelter Plus Care Program Asset Verification Form Tenant/Applicant: This Form is not applicable to tenant TENANT/APPLICANT CERTIFICATION: I do not have any assets. I also understand and agree that if I should receive any such assets, I will report this change to the Program Representative. Tenant/Applicant Signature Date The person named above is a tenant/applicant for a dwelling unit in the above referenced project. Federal law requires us to obtain verification of all assets for each tenant/applicant to determine his/her eligibility for occupancy in the project. The information requested below will be kept in strict confidence. Please complete the section below and return it in the self-addressed envelope.. Thank you for your cooperation in completing and returning this form as soon as possible. I authorize to release all assets and income payable to me from same. (Institution/Agency) Signature of Applicant NET FAMILY ASSETS DO NOT INCLDE: 1. Assets that are NOT effectively owned by the applicant, i.e., when assets are held in an individual s name but: a) the assets and any income they earn accrue to the benefit of someone else; and b) that other person is responsible for income taxes incurred on income generated by the asset. EXAMPLE: Assets held pursuant to a power of attorney because one party is not competent to manage the assets or assets held in a joint account solely to facilitate access to assets in the event of an emergency. 2. Assets are not accessible to the applicant and provide no income to the applicant. EXAMPLE: A battered spouse owns a house with her husband. Because of the domestic situation, she receives no income from the asset and cannot convert the asset to cash. PLEASE GIVE INFORMATION ON THE FOLLOWING: Type of Asset Value Int Rate OR Anticipated Income for next 12 months Checking Account (Avg Bal) _ Savings Account (Current Bal) _ Certificate of Deposit (Dep Amt) _ Money Market (Current Funds) _ Trust Fund (Principal Value) _ Other: _

14 Project Name: Shelter Plus Care Program Shelter Plus Care Program Employment Income Verification Form Tenant/Applicant: This Form is not applicable to tenant TENANT/APPLICANT CERTIFICATION: I am not employed and do not receive any income from employment. I also understand and agree that if I should become employed I will report this change to the Program Representative. Tenant/Applicant Signature Date The person named above is a tenant/applicant for a dwelling unit in the above referenced project. Federal law requires us to obtain verification of all assets for each tenant/applicant to determine his/her eligibility for occupancy in the project. I authorize (employer) to release all information concerning my wages. Signature of Applicant Date Social Security Number Signature of Legal Guardian Date Confidential Employment Information: 1. Date employment began: Occupation/Position: Date of Termination (if applicable): 2. Rate of regular pay per (hour, week, month) 3. Average number of hours worked per week: 4. Average number of weeks worked per year: 5. Total gross earnings for the last six months: 6. Does this employee work overtime? (Y/N) $ per hour, hours per week 7. Do you anticipate any change in the number or hours the employee works? If yes, explain: 8. Effective date of last pay increase:

15 Shelter Plus Care Program Unemployment Benefit Income Verification Form Project Name: Shelter Plus Care Program Tenant/Application: This Form is not applicable to tenant TENANT/APPLICANT CERTIFICATION: I do not receive any employment benefit income. I also understand and agree that if I should receive any such benefits I will report this change to the Program Representative. Tenant/Applicant Signature Date I hereby authorize the release of this information: Signature of Applicant Social Security Number Signature of legal guardian We are requested to verify the income of the above referenced tenant/applicant applying for admission into the Shelter Plus Care Program and to re-examine periodically this tenant/applicant s income. To comply with this requirement, we ask your cooperation in supplying the following income information for the person listed above. This information will be used only in determining the eligibility status and rent of the family. Thank you for your cooperation in completing and returning this form as soon as possible. Section One: Unemployment Benefits Gross Weekly Payment Date of Initial Payment Duration of Benefits weeks Is applicant eligible for future benefits? (Y/N) If yes, number weeks? If not, termination of benefits date? Section one of this form may be verified by the unemployment compensation agency. Signature of Verifier Title Organization Address Telephone Date

16 Project Name: Shelter Plus Care Program Shelter Plus Care Program Social Security Benefit Verification Form Tenant/Applicant: This Form is not applicable to tenant TENANT/APPLICANT CERTIFICATION: I do not receive any income from Social Security. I also understand and agree that if I should receive any such benefits I will report this change to the Program Representative. Tenant/Applicant Signature Date We are required to verify the income of the above referenced tenant/applicant applying for admission as tenants to the federally aided housing units which we operate and to re-examine periodically this tenant/applicant s income. To comply with this requirement, we ask your cooperation in supplying the following income information for the person listed above. This information will be used only in determining the eligibility status and rent of the family. Thank you for your cooperation in completing and returning this form as soon as possible. I hereby authorize the release of this information: Signature of Applicant Date Social Security Number Signature of Legal Guardian Date Social Security Disability Gross monthly payment Amount of monthly Medicare deductions Deductions from amount being recaptured? (Y/N) Monthly recapture amount Total recapture amount Is an increase expected in this amount during the next 12 months? (Y/N) If yes, monthly increase amount Supplemental Security Income Gross monthly payment Amount of Medicate deduction Deductions for amount being recaptured? (Y/N) Monthly recapture amount Total recapture amount Is an increase expected in this amount during the next 12 months? (Y/N) If yes, monthly increase amount

17 Project Name: Shelter Plus Care Program Shelter Plus Care Program Medical Expense Verification Form Tenant/Applicant: This Form is not applicable to tenant. I have explained to tenant that his/her rent might be less each month if he/she consents to verification of medical expenses. However, at this time he/she prefers not to give consent. Program Representative The person named above is a tenant/applicant for a dwelling unit in the above referenced project. Federal law requires us to obtain verification of medical expenses for each tenant/applicant to determine his/her eligibility for occupancy in the project. The information requested below will be kept in strict confidence. Please complete the section below and return it in the self-addressed envelope. Thank you for your cooperation in completing and returning this form as soon as possible. I authorize to release all information (Doctor/Pharmacy/Institution or Agency) they may possess in reference to my medical expenses. Signature of Applicant Date PLEASE GIVE INFORMATION ON THE FOLLOWING: Show only the amount paid by the tenant/applicant. Do not show portion paid by Medicare, Medicaid, Insurance, relatives, etc. Anticipated Amount for next 12 months Anticipated Cost of Prescription Drugs Anticipated Cost of Non-Prescription Drugs Anticipated Expense for Visits to Doctor Anticipated Expense for Visits to Dentist Hospitalization Insurance Premium Past Due Medical Bills Outstanding Identify: Amount tenant is paying toward bill Anticipated Unusual Medical Expenses Non-Prescription drug amounts verified by the residence manager or administrator Anticipated Cost of Non-Prescription Drugs A separate form must be completed by each expense source, i.e., pharmacist, doctor, dentist, etc. A copy of the record(s) verifying this amount is attached. Signature of Verifier Title Organization Address _ Telephone Date