Employee Landlord Letter by vqo83038

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Employee Landlord Letter document sample

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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


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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