Get documents about "Notice of Landlord Inspection
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Notice of Landlord Inspection document sample
Document Sample
Case Manager HPRP DCA Application Checklist
Client Name: 0 Provider Agency
0
CSP # 0
Check Request (All Providers)
Client Name, CSP #, last 4 digits of SSN YES Rent/Deposit/Arrearage Amounts YES
AMI Less than 50% YES Property & Lease Information YES
Landlord Name & Phone Listed YES Destination at exit from program YES
Case Manager Name & Phone Listed YES
Income Sources Form & Documentation (All Providers)
One or more of the following supporting documentation attached: 1) pay stubs, benefit statement
YES
etc.; 2) Verification of Income form; 3) Oral Verification of Income; 4) Self Declaration of Income
Expense Form (All Providers)
Projected Monthly Income Displayed YES Income for past 30 days Entered YES
Actual/Estimate Expense Amounts Listed for each month YES
Calculations Sheet (All Providers)
Explanation of household's plan to afford/sustain housing if housing costs exceed 50% YES N/A
Explanation of plan to pay housing expenses if zero income? YES N/A
Other assistance provided described? YES N/A
Explanation of income used while in program for expenses other than housing costs YES N/A
Client Signature Form (All Providers)
Applicant and Significant Other Signature (when applicable) YES Case Manager and Supervisor Signatures YES
Rapid Re-housing Assessment (Transition, CHN Placement)
All questions answered? YES
Case Manager and Supervisor Signatures and Appropriate Dates YES
Homeless Documentation attached (one of the following): 1) CSP Printout; 2) Homeless Certification YES
Form; 3) Self Declaration of Housing Form
Prevention Assessment (ADAMH, Gladden Community House, CHN Prevention)
All questions answered? YES
Case Manager and Supervisor Signatures and Appropriate Dates YES
Evidence of pending housing loss documentation (one or more of the following): 1)
YES
Hospital/Institution Discharge Statement; 2) Eviction Notice; 3) Foreclosure Notice; 4) Utility
Disconnect Notice; 5) Condemned Notice
Non-Eviction Certification (Gladden) YES
Staff Certification of Eligibility for HPRP Assistance Form (All Providers)
Client's Name, and Case Manager and Supervisor Signatures & Dated YES
Housing Documentation- Submit One- ** A completed lease will need to submitted before HPRP funds can be released **
1) Verification of Prospective Housing Form (Transition or CHN Placement) YES N/A
2) Lease containing the following information:
dated within the past 30 days YES unit address YES landlord contact information YES
client & landlord name YES lease term YES rent/security deposit amounts YES
signed by landlord and tenant YES Lease Addendum YES
Printout of property ownership from Auditor's Website AND one of the following: YES
W-9 on file at CSB YES Property Management Agreement YES N/A
CSP Referral AND Entry Date in the Entry/Exit Record YES
Copy of I.D. for ALL adults in household YES
Utility Assistance (must contain the following information):
Client Name YES Account Number YES
Amount Owed Per Period YES Utility Company Information YES Itemized Statement YES
HPRP Direct Client Assistance
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, that there is
Check Request
Select Program:
Transition ADAMH Prevention CHN Prevention CHN Placement Gladden House Prevention
VOA Rapid Rehousing
Agency Name Date 5/5/2011
Client Name (Last, First) CSP #
Last 4-Digits of SSN % AMI; must be <50%
HPRP DCA Request #
Time Period (M/D/YY) Amount
Current Costs Start Date End Date HPRP Other* Self Pay Vendor
Gas
Electric
Water
Month #1 - Rent
Month #2 - Rent
$0.00 $0.00 $0.00
Time Period (M/D/YY) Amount
Deposits Start Date End Date HPRP Other* Self Pay Vendor
Gas
Electric
Rent
$0.00 $0.00 $0.00
Time Period (M/D/YY) Amount
Arrearages Start Date End Date HPRP Other* Self Pay Vendor
Month #1 - Gas
Month #2 - Gas
Month #1 - Electric
Month #2 - Electric
Month #1 - Water
Month #2 - Water
Month #1 - Rent
Month #2 - Rent
$0.00 $0.00 $0.00
*Cannot be another Federal, State, or local housing subsidy program for the
same period & cost type.
Total HPRP Request Amount $0.00 Destination at exit from program:
(FOR HUD/CSP REPORTING PURPOSES)
Unit Information
HOME SUBSIDIZED housing/apartment
Address and Street
Other SUBSIDIIZED housing/apartment
City / State OH
Public Housing
Zip Code
Rental House/apartment NO SUBSIDY
FBCO Section 8 Shelter Plus Care
Landlord Contact Information
Letter of Guaranty YES
Landlord/Property Manager Name
Landlord/Property Owner Phone Number & area code Name:
Fax #:
Case Manager Name:
Case Manager Phone Number (with area code): PICK UP CHECK YES
CSB Use Only: PM-DCA Approved:______ FA Entered:______ BK Reviewed:______ DPP Released:______
Date: ______ Date:______ Date:______ Date:______
Inspection Date Check Date Account Project
Order Date:
Completion Date: Funder Department % AMI
Pass/Fail:
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HPRP Direct Client Assistance
Income Sources
Client Name: 0 Provider Agency: 0
CSP # 0 Date: 5/5/2011
SINGLE
Verification
Source of Income Amount Attached
Earned Income (i.e., employment)
Unemployment Insurance
Supplemental Security Income (SSI)
Social Security Disability Income (SSDI)
Self Declaration of Zero Income $0.00
Veteran's Disability Payment
Worker's Compensation
Temporary Assistance for Needed Families (TANF)
General Assistance
Retirement Income from Social Security
Veteran's Pension
Child Support
Alimony or other spousal support
Other Source
Total Monthly Income from all sources $0.00
FAMILY
Verification
Source of Income Amount Attached
Earned Income (i.e., employment)
Unemployment Insurance
Supplemental Security Income (SSI)
Social Security Disability Income (SSDI)
Self Declaration of Zero Income $0.00
Veteran's Disability Payment
Worker's Compensation
Temporary Assistance for Needed Families (TANF)
General Assistance
Retirement Income from Social Security
Veteran's Pension
Child Support
Alimony or other spousal support
Other Source
Total Monthly Income from all sources $0.00
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HPRP Direct Client Assistance
Calculations Sheet
Client Name: 0 CSP # 0
Income
Single: Projected Monthly Income $0.00
If ERROR appears, a value has been entered for both Single and
Family: Projected Monthly Income $0.00 Family Income OR no Income has been entered
Family Composition (# household members including HoH):
Is the client pregnant or will there be a pregnant occupant residing YES NO
in the proposed unit (for purposes of lead inspection)?
Projected Monthly Housing Cost: Percentage of Monthly Income
Rent Does "Projected Monthly Housing Cost" exceed 50% of the household's
Gas monthly income?
Electricity Single: #DIV/0! > 50%? #DIV/0!
Water Family: #DIV/0! > 50%? #DIV/0!
Total Monthly
Cost $0.00
If "Projected Monthly Housing Cost" is more than 50% 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?
Please describe other cash assistance the client is receiving or has received through other community resources.
Date Amount Funding Source Type (rent, utilities, deposit, moving cost, etc.)
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, arrears, moving expense (U-Haul), app. 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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HPRP Direct Client Assistance
Household Monthly Expenses
Client Name: 0 CSP # 0
Income
Single: Projected Monthly Income $0.00
Family: Projected Monthly Income $0.00
Household Monthly Expenses
Please provide a monthly cost for each applicable monthly expense.
If there is no expense, leave field blank.
Monthly Expenses Month #1 Month #2
Client/Household Income for the Past 30 days
Rent
House/Apartment Security Deposit
Electricity
Electric Deposit
Gas (for heating)
Water
Food/Hygiene Items (amount after Food Stamps)
Phone (cell phone or land line)
Child Care/Babysitter (not child support)
Gas (for car)
Credit Cards (exclusive of food bill or other expenses paid
with credit card)
Car Insurance
Bus tickets
Laundromat Washing & Drying
Car Payment
Monthly Child Support Payment (not child care)
Other Monthly Expenses to sustain housing that is not listed
above (please describe & provide monthly expense amount)
Maximum HPRP
Total Monthly Expenses $0.00 $0.00 allowed this
request
Maximum HPRP DCA Allowed Per Month $0.00 N/A $0.00
A negative number in the Maximum HPRP DCA Allowed Per Month indicates the remaining
income the household should have each month after expenses. Therefore, HPRP financial
assistance cannot be used.
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HPRP
Direct Client Assistance
Client Signature Form
Client Name: 0
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 "but for this assistance" I would be homeless; I can remain stably housed
after this temporary assistance; my income is less than 50% of Area Median Income (AMI); and I have no
financial resources or support networks to remain in housing.
I certify that all the information provided in this application regarding my current housing situation, utilities,
and income is true and accurate to the best of my knowledge. I also understand that submission of
fraudulent information and/or documentation with intent to obtain HPRP funds will result in in local law
enforcement and FBI investigation and prosecution. Title 18, Section 1001 of the U.S. Code states that a
person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any
department of the United States Government.
I certify that I have received a copy of the agency's grievance and appeals process.
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 HPRP Direct Client Assistance Program. I also certify a thorough
comprehensive interview has been conducted and all supporting documentation has been obtained to
determine the above client's eligibility to apply for HPRP assistance.
Case Manager:________________________ Signature: ________________________ Date: _______
Print Name Signature
Supervisor:__________________________ Signature: _________________________ Date: ________
Print Name Signature
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Second/Third Month's Request and/or Re-Assessment HPRP DCA Checklist
Client Name: 0 Provider Agency
0
CSP # 0
Check Request (All Providers - 2nd/3rd Month and Re-Assessment)
Client Name, CSP #, last 4 digits of SSN YES Rent/Deposit/Arrearage Amounts YES
AMI Less than 50% YES Property & Lease Information YES
Landlord Name & Phone Listed YES Destination at exit from program YES
Case Manager Name & Phone Listed YES
Income Sources Form & Documentation (All Providers - 2nd/3rd Month (if income has changed) and Re-Assessment)
One or more of the following supporting documentation attached: 1) pay stubs, benefit statement
YES
etc.; 2) Verification of Income form; 3) Oral Verification of Income; 4) Self Declaration of Income
Case Manager Section completed on Oral Verification and/or Self Declaration of Income Form? YES N/A
Expense Form (All Providers - 2nd/3rd Month and Re-Assessment)
Projected Monthly Income Displayed YES Income for past 30 days Entered YES
Actual/Estimate Expense Amounts Listed for each month YES
Calculations Sheet (All Providers - 2nd/3rd Month and Re-Assessment requests)
Explanation of household's plan to afford/sustain housing if housing costs exceed 50% YES N/A
Explanation of plan to pay housing expenses if zero income? YES N/A
Other assistance provided described? YES N/A
Explanation of income used while in program for expenses other than housing costs YES N/A
Client Signature Form (All Providers - 2nd/3rd Month's and Re-Assessment)
Applicant and Significant Other Signature (when applicable) YES
Case Manager and Supervisor Signatures YES
Continued Tenancy & Client Need Certification (All Providers - 2nd/3rd Month's Requests)
Completed with client, address, rent amount, month due, and client & landlord signatures? YES
Rapid Re-housing Assessment (Transition & CHN Placement - Re-Assessment after 3 months)
All questions answered? YES
Case Manager and Supervisor Signatures and Appropriate Dates YES
Homeless Documentation attached (one of the following): 1) CSP Printout; 2) Homeless Certification YES
Form; 3) Self Declaration of Housing Form
Prevention Assessment (ADAMH, Gladden Community House, & CHN Prevention - Reassessment after 3 months)
All questions answered? YES
Case Manager and Supervisor Signatures and Appropriate Dates YES
Evidence of pending housing loss documentation (one or more of the following): 1)
YES
Hospital/Institution Discharge Statement; 2) Eviction Notice; 3) Foreclosure Notice; 4) Utility
Disconnect Notice; 5) Condemned Notice
Staff Certification of Eligibility for HPRP Assistance Form (All Providers - Re-Assessment after 3 months)
Client's Name, and Case Manager and Supervisor Signatures & Dated YES
CSP Referral AND Entry Date in the Entry/Exit Record YES
Utility Assistance (must contain the following information):
Client Name YES Account Number YES
Amount Owed Per Period YES Utility Company Information YES Itemized Statement YES
ADDENDUM TO LEASE AGREEMENT
THIS ADDENDUM TO LEASE AGREEMENT (this "Addendum") is effective as of ________________
(the "Effective Date"), and is being signed simultaneously with the Lease (the "Lease") dated
_________________, 20_____ between ________________________ (the "Tenant") and
________________________ (the "Landlord") for the real property commonly known as (the
"Premises").
1. Incorporation and Precedence. This Addendum is incorporated into the Lease and supersedes
any conflicting provisions in it.
2. Background.
The Landlord understands that the Tenant intends to obtain rental assistance from The
a) Community Shelter Board ("CSB") through the Homelessness Prevention and Rapid Re-
Housing Direct Client Assistance Program ("HPRP DCA").
A housing inspection must be performed by CSB prior to the Tenant taking possession of
b)
the Premises. The inspection shall include some, if not all, of the following: standard
habitability requirements, rent reasonableness, and a visual lead-based paint assessment.
Rental assistance will be provided to Tenant by CSB only after successful completion of the
c)
housing inspection.
3. Financial Obligation. Landlord agrees Tenant shall not be held to any financial obligations prior to
the date of actual occupancy, with the exception of payment of any Landlord-required security
deposit.
4. Rental Contingency. Landlord agrees that Tenant's responsibility to fulfill the duties of this Lease
is contingent upon the unit passing all CSB-required housing inspections and prospective tenant's
approval for financial assistance. Landlord further agrees that the Tenant shall not be held to the
obligations of this Lease if such conditions are not met.
Intending to be bound, the Landlord and the Tenant sign and deliver this Addendum effective on the
Effective Date, regardless of the actual date of signature.
Landlord Tenant
(signature) (signature)
Name:_______________________________ Name:___________________________________
Phone:_________________ Phone:_________________
HPRP Continued Tenancy and Client Need Certification
Continued Tenancy Certification
I, _________________________________, under penalty of perjury, certify the tenant
(print name of landlord or property manager)
indicated below continues to reside at the address below and has rent due in the amount
indicated below.
Tenant Name:__________________________________________________
Unit Address:__________________________________________________
City, State, Zip Code:____________________________________________
Rent Amount Due:$______________ for the month of ____________________ 20______.
Landlord/Property Manager Signature:____________________________________________
Printed Name of Landlord/Property Manager:_____________________________________
Date:________________________
Client Continued Need Certification
I, __________________________________, under penalty of perjury, declare that I am still in
(print client name)
need of financial assistance for my rent during the month of
____________________________ 20___.
Client Signature:____________________________________________
Printed Client Name:________________________________________
Date:________________________
Once completed, please submit this form and the Client Signature Form to your Case
Manager.
Client Name: 0
HPRP Homelessness Prevention
CSP #: 0 Client Eligibility Assessment
Threshold eligibility criteria:
1. At imminent risk of homelessness and but for this assistance would be homeless.
Part 1: Evidence of pending loss of housing: must have evidence of at least one reason for imminent loss of
current housing. Check one or more and attach all relevant documentation .
Notice from landlord of eviction from landlord/property manager due to non-payment of rent and copy of
lease naming applicant as leaseholder.
Copy of notice indicating building in which applicant is renting or otherwise resident is being foreclosed
on and copy of lease naming applicant as leaseholder.
Notice from landlord of eviction due to non-payment of utilities and copy of lease naming applicant as
leaseholder.
Copy of eviction letter from host renter/homeowner verifying that applicant is must leave and copy of
lease or title naming host renter/homeowner as leaseholder/title holder.
Signed and dated utility disconnect notice in applicant’s name from utility company that indicates shutoff
is imminent.
Signed and dated copy of foreclosure notice from lending institution that identifies applicant is the
homeowner and that the applicant must leave their housing.
Signed and dated copy of notice from landlord/property manager, public health, code enforcement, fire
marshal, child welfare, or other government entity that housing is condemned and copy of lease naming
applicant as leaseholder.
Written statement from hospital or other institution that verifies current stay of applicant and indicates
applicant has no housing to return to upon discharge.
Part 2: Evidence of no other housing options: case manager assessment that other options are not available to
applicant. Verify through comprehensive interview .
Yes No
Can family members provide housing or sufficient financial assistance to applicant?
Can friends provide housing assistance to applicant?
Has the applicant accessed all available community resources to avoid homelessness?
Can the applicant afford to maintain current housing or gain new housing without HPRP
financial assistance?
Part 3: Evidence lack of financial resources and support networks: case manager assessment that other
options are not available to applicant. Verify through comprehensive interview.
Yes No
Can family members can provide housing or sufficient financial assistance to applicant?
Is the amount in checking and savings bank accounts is less than $500.00?
2. Income at or below 50% Area Median Income (AMI).
Attach income documentation and computation of AMI.
3. Ability to remain stably housed after assistance is provided.
Attach computation that total housing costs are at or below 50% monthly income.
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Client Name: 0
HPRP Homelessness Prevention
CSP #: 0 Client Eligibility Assessment
Targeting criteria will apply to ensure that household at greatest risk are served:
Case Manager assessment must confirm at least one of the targeting criteria is met.
Check one or more and attach documentation and/or verify through comprehensive interview.
Housing Instability
Discharge within 2 weeks from an institution with no housing options available.
High overcrowding (the number of persons exceeds health and/or safety standards for the housing unit size)
Sudden and significant increase in utility costs
Severe housing cost burden (greater than 50% of income for housing costs)
History of homelessness in last 12 months
Income instability
Extremely low income (less than 30 percent of Area Median Income)
Credit problems that preclude obtaining of housing
Significant amount of documented medical debt
Sudden and significant loss of income
Personal issues
Mental health and substance abuse issues
Physical disabilities and other chronic health issues, including HIV/AIDS
Young head of household (under 25 with children or pregnant)
Current pregnancy of adult or recent birth of child (less than 24 months)
Current or past involvement with child welfare, including foster care
Past institutional care (prison, treatment facility, hospital)
Recent traumatic life event, such as domestic violence, death of a spouse or primary care provider, or recent health
crisis that prevented the household from meeting its financial responsibilities
Case Manager (print name)
Case Manager Signature:
Date of Assessment:
Supervisor Name (print name)
Supervisor Signature
Date of Approval:
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HPRP Guarantee of Non-Eviction Certification
Guarantee of Non-Eviction Certification
I, _________________________________, under penalty of perjury, certify that acceptance
(print name of landlord or property manager)
of rental payment for the tenant listed below will guarantee housing to the program
participant for a minimum of 30 days and as long as the tenant is in good standing with their
lease, and that I/we will not evict the tenant during that time period.
I/We further understand that the application process and receipt of payment for rent may
take up to 15 days to complete, and during this waiting period will not evict the tenant from
his/her unit.
Tenant Name:__________________________________________________
Unit Address:__________________________________________________
City, State, Zip Code:____________________________________________
Landlord/Property Manager Signature:____________________________________________
Printed Name of Landlord/Property Manager:_____________________________________
Date:________________________
Client Name: 0
HPRP Rapid Re-Housing
CSP #: 0 Client Eligibility Assessment
Threshold eligibility criteria:
1. Homeless (residing in emergency shelter or living on streets).
Part 1: Check one or more and attach all relevant documentation.
If sleeping in shelter or graduating/timing out of transitional housing: Active record in CSP as current
participant of emergency shelter or transitional housing. Print out and place in file.
If sleeping in a place not meant for human habitation: Signed and dated original Homeless Certification
form from street outreach provider.
If domestic violence situation: Signed and dated original Self Declaration of Housing Status.
Part 2: Evidence of no other housing options: case manager assessment that other options are not available to
applicant. Verify through comprehensive interview .
Yes No
Can family members provide housing or sufficient financial assistance to applicant?
Can friends provide housing assistance to applicant?
Has the applicant accessed all available community resources to avoid homelessness?
Can the applicant afford to maintain current housing or gain new housing without HPRP
financial assistance?
Part 3: Evidence lack of financial resources and support networks: case manager assessment that other
options are not available to applicant. Verify through comprehensive interview .
Yes No
Can family members provide housing or sufficient financial assistance to applicant?
Is the amount in checking and savings bank accounts is less than $500.00?
2. Income at or below 50% Area Median Income (AMI).
3. Ability to remain stably housed after assistance is provided.
Attach computation that total housing costs are at or below 50% monthly income.
If not at or below 60% of monthly income, attach request for exception to this guideline and
statement about how client will sustain housing.
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Client Name: 0
HPRP Rapid Re-Housing
CSP #: 0 Client Eligibility Assessment
Targeting criteria will apply to ensure that households at greatest risk are served:
Case Manager assessment must confirm at least one of the targeting criteria is met.
Check one or more and attach documentation and/or verify through comprehensive interview.
Housing Instability
Homeless more than two weeks and staying in emergency shelter or on the streets
History of homelessness
Income instability
Extremely low income (less than 30 percent of Area Median Income)
Credit problems that preclude obtaining of housing
Significant amount of documented medical debt
Sudden and significant loss of income, including recent unemployment
Personal issues
Mental health and substance abuse issues
Physical disabilities and other chronic health issues, including HIV/AIDS
Transition age youth/young adult (16-21 years of age)
Young head of household (under 25 with children or pregnant)
Pregnant woman
Current or past involvement with child welfare, including foster care
Past institutional care (prison, treatment facility, hospital)
Recent traumatic life event, such as domestic violence, death of a spouse or primary care provider, or recent health
crisis that prevented the household from meeting its financial responsibilities
Case Manager (print name)
Case Manager Signature:
Date of Assessment:
Supervisor Name (print name)
Supervisor Signature
Date of Approval:
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Client Name: 0
HPRP
CSP #: 0 Verification of Income
Instructions for Employer/Payment Source Representative: This is to certify the income received by the above
named individual for purposes of participating in the HPRP program. Complete only the selected section below
that includes an authorization to release information.
Please return this form to:
Name & Title: ________________________________________ Phone:__(__________)_______________
Address:____________________________________________ Fax:__(__________)_______________
Email:_______________________________________________
Employment Income
Client Release: I hereby authorize the release of the following employment information.
Client Signature:___________________________________________ Date:_________________
Please be sure the
employer completes
Employer representative to complete this section:
information about the
client's work
The person name above is employed by _______________________________________________ since signs/dates the form.
_______________________. He/she is paid $______________ on an hourly/week/monthly (circle one) basis
and is current working an average of ____________ hours per ___________ week.
Please specify any additional compensation:______________________________________________________
Probability of continued employment:_______________________________
Authorized Employer Representative Signature________________________________ Date:_____________
Name and Title (please print):_________________________________________________
Address and Phone Number:__________________________________________________________________
Payments/Benefits Income
Complete one form for each distinct source of income for person named above.
Circle one
Social Security/SSI Pension/Retirement TANF
Public Assistance Unemployment Compensation Workers Compensation
Alimony Payments Foster Care Payments Child Support Payments
Armed Forces Income
Other (please specify):______________________________________________
Client Release: I hereby authorize the release of the following payment/benefits information.
Client Signature:___________________________________________ Date:_________________
Payment source representative to complete this section
Payments or benefits in the amount of $_______________________ are paid on a ______________________
Authorized Payment Source of the payments or benefits
basis. The expected durationRepresentative Signature: is _____________________________.
_____________________________Date:____________
Name, Title: _______________________________________________________________________________
Address and Phone:
_________________________________________________________________________
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Client Name: 0
HPRP
CSP #: 0 Oral Verification of Income
Instructions for Case Managers: This is to certify the income received by the above named individual for
purposes of participating in the HPRP program. This will document telephone conversations between you and
the representative of the employer and/or income source.
PLEASE INDICATE THE REASON FOR ORAL VERIFICATION:______________________________________________________
__________________________________________________________________________________________
I hereby certify the income verification information contained in this form is accurate to the best of my abilities.
Case Manager Signature:________________________________ Date:___________________
Complete only the selected section below that includes an authorization to release information.
Employment Income
Client Release: I hereby authorize the release of the following employment information.
Client Signature:___________________________________________ Date:_________________
CASE MANAGER TO COMPLETE THIS SECTION
The person named above is employed by ______________________________________since
_______________. He/she is paid $______________ on a _____________ hourly/weekly/monthly (circle
one) basis and is currently working an average of _____________hours per ____________.
Additional compensation please specify (if any):___________________________________________________
Probability of continued employment: __________________________________________________________
Authorized Employer Representative Name and Title: ______________________________________________
Address and Phone: ________________________________________________________________________
Date Verification was obtained: _____________________
Payments/Benefits Income
Complete one form for each distinct source of income for person named above.
Circle one
Social Security/SSI Pension/Retirement TANF
Public Assistance Unemployment Compensation Workers Compensation
Alimony Payments Foster Care Payments Child Support Payments
Armed Forces Income
Other (please specify):______________________________________________
Client Release: I hereby authorize the release of the following payment/benefits information.
Client Signature:___________________________________________ Date:_________________
CASE MANAGER TO COMPLETE THIS SECTION
Payments or benefits in the amount of $_______________________ are paid on a ______________________
basis. The expected duration of the payments or benefits is _____________________________.
Authorized Payment Source Representative Name, Title:
_______________________________________________________________________________________
Address and Phone:
__________________________________________________________________________
Date verification was obtained: _____________________
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___________
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Client Name: 0
HPRP
CSP #: 0 Self Declaration of Income
This is to certify the income status for the above named individual. Income includes but is not limited to:
• The full amount of gross income earned before taxes and deductions.
The net income earned from the operation of a business, i.e., total revenue minus business
• operating expenses. This also includes any withdrawals of cash from the business or profession for
your personal use.
• Monthly interest and dividend income credited to an applicant’s bank account and available for use.
The monthly payment amount received from Social Security, annuities, retirement funds, pensions,
•
disability and other similar types of periodic payments.
Any monthly payments in lieu of earnings, such as unemployment, disability compensation, SSI,
•
SSDI, and worker's compensation.
Monthly income from government agencies excluding amounts designated for shelter, and utilities,
•
WIC, food stamps, and childcare.
Alimony, child support and foster care payments received from organizations or from persons not
•
residing in the dwelling.
All basic pay, special day and allowances of a member of the Armed Forces excluding special pay
•
for exposure to hostile fire.
CHECK ONLY ONE BOX AND COMPLETE THAT SECTION.
I certify, under penalty of perjury, that I currently receive the following income:
Source:________________________________ Amount: $______________ Frequency:_____________
Source:________________________________ Amount: $______________ Frequency:_____________
Source:________________________________ Amount: $______________ Frequency:_____________
I certify, under penalty of perjury, that I do not have any income from any source at this time.
Client Signature:_______________________________________ Date:___________________
CASE MANAGER VERIFICATION
I understand that third-party verification is the preferred method of certifying income for HPRP assistance. I
understand self-declaration is only permitted when I have attempted to but cannot obtain third party verification.
Case Manager Signature:____________________________________ Date:_______________
Supervisor Signature:________________________________________ Date:_______________
Documentation of attempt made for third party verification.
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Homelessness Prevention and Rapid Re-Housing
Verification of Prospective Housing
Client Information CSP # 0
Prospective Tenant Name:
Unit Address:
City, State, Zip
Monthly Rent Amount for Unit (including
any utility payments due with rent) $
Security Deposit Amount $
Move In Date
(pending successful housing inspection) / /
Prospective Landlord Information
I hereby agree that I intend to rent the above-listed unit to the above-named prospective tenant. I
agree that the unit is available, and understand leasing is contingent upon the unit passing CSB-
required housing inspections and prospective tenant’s approval for financial assistance. To the best
of my knowledge, I certify the above listed information is accurate and true.
Landlord Signature
Date / /
Landlord Name:
Landlord Address:
Landlord Phone Number: ( )
Landlord Fax Number: ( )
Referring Agency Information
Case Manager:
Phone Number: ( )
Referring Agency:
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Homelessness Prevention and Rapid Re-Housing
Homelessness Certification
Client Name: 0
CSP #: 0
Household without dependent children (complete one form for each adult in the household)
Household with dependent children (complete one form for household)
Number of persons in the household: _________
This is to certify that the above named individual or household is currently homeless based on the check mark,
other indicated information, and signature indicating their current living situation.
Please complete one section below.
Living Situation: Place not meant for human habitation (cars, parks, abandoned buildings, streets/sidewalks)
The person(s) named above is/are currently living in (or, if currently in hospital or other institution,
was living in immediately prior to hospital/institution admission) a public or private place not designed
for, or ordinarily used as a regular sleeping accommodation for human beings, including a car, park,
abandoned building, bus station, airport, or camp ground.
Description of Current Living Situation:
Homeless Street Outreach Program:
This certifying agency must be recognized by the local Continuum of Care (CoC) as an agency that has a
program designed to serve persons living on the street or other places not meant for human habitation.
Agency Representative Signature:____________________________________ Date:_________________
Living Situation: Transitional Housing
The person(s) named above is/are currently living in a transitional housing program for persons who
are homeless. The persons(s) named above is/are graduating from or timing out of the transitional
housing program:
Transitional Housing Program Name:
This transitional housing program must appear on the CoC’s Housing Inventory Chart submitted as part of the
most recent CoC Homeless Assistance application to HUD or otherwise be recognized by the CoC as part of
the CoC inventory (e.g. newly established Transitional Housing program).
Immediately prior to entering transitional housing the person(s) named above was/were residing in:
Emergency Shelter
OR
A place unfit for human habitation
Agency Representative Signature:____________________________________ Date:_________________
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Homelessness Prevention and Rapid Re-Housing
Self Declaration of Housing Status
Client Name: 0
CSP #: 0
Household without dependent children (complete one form for each adult in the household)
Household with dependent children (complete one form for household)
Number of persons in the household: _________
This is to certify that the above named individual or household is currently homeless or at-risk of homelessness,
based on the following and other indicated information and the signed declaration by the applicant.
Please complete BOTH sections below.
Client Verification
Check one of the following:
I [and my children] am/are currently homeless and living on the street (i.e. a car, park, abandoned
building, bus station, airport, or camp ground).
I [and my children] am/are the victim(s) of domestic violence and am/are fleeing from abuse.
I certify that the information above and any other information I have provided in applying for HPRP assistance is
true, accurate and complete.
Client Signature:__________________________________________ Date:___________________
Case Manager Verification
I understand that third-party verification is the preferred method of certifying homelessness or risk for
homelessness for an individual who is applying for HPRP assistance. I understand self declaration is only
permitted when I have attempted to but cannot obtain third party verification.
Case Manager Signature:_______________________________________ Date:__________________
Supervisor Signature:__________________________________________ Date:__________________
Documentation of attempt made for third-party verification:
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Project Welcome Home Request Form
Name (Last, First MI): 0 CSP # 0
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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Furniture Bank of Central Ohio Request
If you are requesting FBCO for your client, check the
FBCO box on the Check Request form.
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Family Size 1 Person 2 People 3 People 4 People 5 People 6 People 7 People 8 People
Very Low Income (50%) $24,050 $27,450 $30,900 $34,300 $37,050 $39,800 $42,550 $45,300
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 HPRP CSB Direct Client Assistance
All HPRP DCA trained staff are required to have this form on file with CSB before they
can begin to submit HPRP DCA 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/Fax: Fax: ( )
Employee Phone #:
Employee Signature:
Date:
This employee is authorized to (please check all that apply):
Submit HPRP DCA applications
Pick-up checks from CSB
Sign off as a supervisor on HPRP 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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