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Direct Client Assistance
Check Request
I hereby apply for the amount written above to be paid to the listed payee. I understand this is a grant to be used only for the purpose listed above,
Select Program:
Transition FHC Direct Housing Stable Families USHS Move-Up Pilot
Agency Name Date 1/31/2011
HoH Name (Last, First) CSP #
(LAST) (FIRST)
Last 4-Digits of SSN % AMI
Rent Assistance
RENT
DEPOSIT
$0.00
Vendor Request Number 1
Utility Assistance
Gas Vendor
Electric Vendor
Water Vendor
Other Assistance (please provide vendor & a description)
Vendor
Total Request Amount $0.00
FBCO
Is this request for agency reimbursement? P/U Check Attn:
Yes => include copy of check for reimbursement LOG Req Fax #:
No
Reason for
LOG:
Address of Property
Address and Street
City State OH
Zip Code
CSB Use Only: PM-DCA Approved:______ FA Entered:______ BK Reviewed:______ DPP Released:______
Date: ______ Date:______ Date:______ Date:______
Check Date Account Project
Funder Department % AMI
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Direct Client Assistance
Calculations Sheet
Client Name: 0 0 CSP # 0
Income
Single: Monthly Income
If ERROR appears, a value has been entered for both Single and
Family: Monthly Income ERROR Family Income OR no Income has been entered
Family Composition (# household members including HoH):
Projected Monthly Housing Cost: Percentage of Monthly Income
Rent Does "Projected Monthly Housing Cost" exceed 40% of the single or 50% of
Gas the family's monthly income?
Electricity Single: #DIV/0! > 40%? #DIV/0!
Water Family: #DIV/0! > 50%? #DIV/0!
Total Monthly
Cost $0.00
If "Projected Monthly Housing Cost" is more than 40% (or 50% for families) of monthly income [the above says
"yes"] , please explain household's plan to afford and sustain housing below.
If client has zero income, how does the client plan to pay housing expenses?
If client is receiving or received cash assistance through other community resources for housing, please describe below
the amount and source.
Source:
Amount:
Request Justification
Please provide a break-down of the amount the household needs to move or retain current housing, what they are
contributing, what other resources they were able to access, and the total of the request (should match check request).
Also provide information about program entry and income earned while in current living situation.
Total Cost for Move-in (includes rent/deposit, utilities, application fee, etc.)
Total Client Contribution
Total of Other Resources
Total Amount Requested $0.00 Total from Check Request $0.00
Total Amount Requested = Total from Check Request? YES
If the cell above reads, "ERROR," the Total Amount Requested on this form does not match the Total from the
DCA Check Request.
If total income received while in program/shelter was used for expenses other than housing costs, please describe.
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Direct Client Assistance
Client Signature Form
Client Name: 0 0
(last) (first)
CSP #: 0
I hereby apply for the amount written above to be paid to the listed payee/vendor. I understand
this grant is to be used only for the purpose listed above, and there is no guarantee I will receive
all or any of the requested amount, and that I am not expected to repay any portion of funds
legally issued as requested. I understand I should remain in my current living situation until my
application is complete and approved by CSB. If I should move prior to approval, I may not receive
all or part of the requested money, and therefore, may lose my housing.
In signing below, I declare that I am presently homeless either in a shelter or I am living on the
streets or other place not meant for human habitation. The only exception is participants in the
Stable Families Prevention Program.
Check the box that applies to your current living situation: Shelter Streets Stable Families
I certify, under penalty of perjury, that I do not have any income from any source at this time. Yes
(not applicable for USHS Move-Up)
Applicant:__________________________ Signature: _________________________ Date: _________
Print Name Signature
Significant Other:_____________________ Signature: ________________________ Date: _________
Print Name Signature
In signing below, I certify all information in this request is complete, accurate and appropriate per
the policies and procedures of CSB's Direct Client Assistance Program.
Case Manager:________________________ Signature: ________________________ Date: _______
Print Name Signature
Supervisor:__________________________ Signature: _________________________ Date: ________
Print Name Signature
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DCA Application Checklist
CSP # 0 Provider Agency:
Client Name: 0 0 0
(last) (first)
Entry date in CSP Entry/Exit Record YES
CSP Referral YES
Check Request
Agency Name Displayed YES Rent/Deposit Amount(s) YES
CSP # on form YES AMI % displayed YES
Client First & Last Name on form YES Complete Property Address YES
Vendor YES Utility Request Amount/Vendor YES N/A
Calculations Sheet
Income documentation included in accordance with DCA P&P's YES N/A
Client First & Last Name on form YES Family Composition Entered YES
CSP # on form YES Projected Monthly Housing Costs Entered YES
Explanation of household's plan to sustain housing if housing costs exceed 40%-single or 50%-family YES N/A
Explanation of plan to pay housing expenses if zero income? YES N/A
(Zero Income not applicable for USHS Move-Up)
Other assistance received described? YES N/A
Explanation of income used while in program for expenses other than housing costs YES N/A
Client Signature Form
Client First & Last Name on form YES
CSP # on form YES
Applicant Signature on Form YES Significant Other Signature on Form YES N/A
Case Manager Signature on Form YES
Supervisor Signature on Form YES
Landlord Verification (must provide one of the following):
Landlord letter OR Signed Lease. Must contain the following:
Dated within the last 30 days YES Rent/Deposit Amounts YES
Client Name YES Signed by Landlord/Property Manager YES
Unit Address YES Landlord Name & Address YES
Property Ownership
Printout from Auditor's website YES
W-9 YES on file at CSB
Property Management Agreement YES N/A
Utility Request (must contain the following information):
Client Name YES Utility Company Name YES
Account Number YES Dated within the past 30 days YES
Amount Owed YES
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Project Welcome Home Request Form
Name: 0 0 CSP # 0
(last) (first)
Address & Street: 0
City: 0 State OH
Zip Code: 00000
Family Members (including HoH listed above):
Name Age
Special needs (i.e. baby formula, feminine hygiene products, school supplies)?
Client Signature
Case Worker Name
Agency Provider 0
Case Worker Signature
Case Worker Contact (phone/email)
Pickup Date Tuesday 2 p.m. __________________________
Date
Thursday 2 p.m. _________________________
Date
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Family Size 1 Person 2 People 3 People 4 People 5 People 6 People 7 People 8 People
30 % of Median $14,400 $16,500 $18,550 $20,600 $22,250 $23,900 $2,555 $27,200
Very Low Income (50%) $24,050 $27,450 $30,900 $34,300 $37,050 $39,800 $42,550 $45,300
Low Income (80%) $38,450 $43,900 $49,400 $54,900 $59,300 $63,700 $68,100 $72,450
Median Income $48,100 $54,900 $61,800 $68,600 $74,100 $79,600 $85,100 $90,600
FY2010 Median 4 Person Family Income $68,600
Effective May 17, 2010
Note:
Income limits are revised periodically
The must current limites are available on the internet at:
http://www.huduser.org/datasets/il.html
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Agency Authorization form for CSB Direct Client Assistance
All DCA trained staff are required to have this form on file with CSB before they can begin
to submit application packets. Please work with your immediate supervisor to complete
this form. Those in supervisory positions should have the person they report to complete
this form.
Name of Agency:
Employee Name:
Employee Email:
Employee Phone #:
Employee Signature:
Date:
This employee is authorized to (please check all that apply):
Submit DCA applications
Pick-up checks from CSB
Sign off as a supervisor on DCA applications*
*This box should only be check off for those who are in supervisory positions.
Supervisor Name:
Supervisor Phone #:
Supervisor Email:
Supervisor Signature:
Date:
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Columbus ServicePoint Data for Agencies Without CSP Access -- Head of Household Wksheet
(e.g. CHOICES, CHN non-RL clients)
Head of Household Information:
HoH Name (Last, First MI)
Alias Name (Last, First, MI)
Date of Birth Gender F M SSN
Race Ethnicity
Is client homeless? Is client chronically homeless?
Homeless Primary Reason Homeless Secondary Reason
Residence Prior to Program Entry:
Residence
Length of Stay at Residence
General Area Location
Street Name City State
Zip Code
Program Entry Date Program Exit Date
Current Residence:
General Area Location
Street Name City State
Zip Code
Disability Information:
Disabling Condition Yes No Disability Type
Employment:
Employed? Yes No Average # of hrs worked/week
Employment Tenure If unemployed, is client looking for work?
Income & Non-Cash Benefit Information (Last 30 Day Income):
Income Source Income Amount
Income Source Income Amount
Income Source Income Amount
Income Source Income Amount
Income Source Income Amount
Total Monthly Income
Services Received:
Service Type Date of Service
Service Type Date of Service
Service Type Date of Service
Service Type Date of Service
Service Type Date of Service
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Education:
Highest Level of School Completed
Currently in school or working on a degree/certificate?
Pregnancy Status:
Pregnant?
Due Date
Additional Information:
Telephone Number
Driver's License #
Veteran's Status Yes No
Is client Rebuilding Lives eligible?
Is client Critical Access to Housing Eligible?
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Columbus ServicePoint Data for Agencies Without CSP Access -- Family Members Wksheet
(e.g. CHOICES, CHN non-RL clients)
1. Family Member Information:
Name (Last, First MI)
Alias Name (Last, First, MI)
Date of Birth Gender F M
SSN
Race Ethnicity
Is client homeless? Is client chronically homeless?
Employment:
Employed? Yes No Average # of hrs worked/week
Employment Tenure If unemployed, is client looking for work?
Income & Non-Cash Benefit Information (Last 30 Day Income):
Income Source Income Amount
Income Source Income Amount
Income Source Income Amount
Income Source Income Amount
Income Source Income Amount
Total Monthly Income
Education:
Highest Level of School Completed
Currently in school or working on a degree/certificate?
Pregnancy Status:
Pregnant?
Due Date
Veteran's Status:
Veteran's Status (for all adults) Yes No
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2. Family Member Information:
Name (Last, First MI)
Alias Name (Last, First, MI)
Date of Birth Gender F M
SSN
Race Ethnicity
Is client homeless? Is client chronically homeless?
Employment:
Employed? Yes No Average # of hrs worked/week
Employment Tenure If unemployed, is client looking for work?
Income & Non-Cash Benefit Information (Last 30 Day Income):
Income Source Income Amount
Income Source Income Amount
Income Source Income Amount
Income Source Income Amount
Income Source Income Amount
Total Monthly Income
Education:
Highest Level of School Completed
Currently in school or working on a degree/certificate?
Pregnancy Status:
Pregnant?
Due Date
Veteran's Status:
Veteran's Status (for all adults) Yes No
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3. Family Member Information:
Name (Last, First MI)
Alias Name (Last, First, MI)
Date of Birth Gender F M
SSN
Race Ethnicity
Is client homeless? Is client chronically homeless?
Employment:
Employed? Yes No Average # of hrs worked/week
Employment Tenure If unemployed, is client looking for work?
Income & Non-Cash Benefit Information (Last 30 Day Income):
Income Source Income Amount
Income Source Income Amount
Income Source Income Amount
Income Source Income Amount
Income Source Income Amount
Total Monthly Income
Education:
Highest Level of School Completed
Currently in school or working on a degree/certificate?
Pregnancy Status:
Pregnant?
Due Date
Veteran's Status:
Veteran's Status (for all adults) Yes No
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