Docstoc

Property Checklist Landlord Tenant

Document Sample
Property Checklist Landlord Tenant Powered By Docstoc
					                                                                        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


                  Agency Name                                                                                                       Date                7/27/2011

   Client Name (Last, First)                                                                                                       CSP #
       Last 4-Digits of SSN                                                                                 % AMI; must be <50%                        0%
      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
                               Water
                                 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)
Property & Lease Information
                                                                                                                             HOME SUBSIDIZED housing/apartment
              Address and Street
                                                                                                                             Other SUBSIDIIZED housing/apartment
                          City / State                                                          OH
                                                                                                                             Public Housing
                           Zip Code
                                                                                                                             Rental House/apartment NO SUBSIDY

   Length of Lease (months):                                                                                                 Section 8                   Shelter Plus Care
                                                                                                                             VASH SUBSIDIZED housing/apartment
Landlord Contact Information
                     Landlord or Property Manager Name
             Phone Number to Contact Landlord or Property
                               Manager (with area code):

                                            Case Manager Name:
             Case Manager Phone Number (with area code):


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:



      D:\Docstoc\Working\pdf\fb757dfb-d91e-45f1-a869-541e03c5be02.xls
                                                             HPRP Direct Client Assistance
                                                                  Income Sources



Client Name:        0                                            Provider Agency:     0

CSP #               0                                            Date:                    7/27/2011

SINGLE
                                                                                                      Verification
Source of Income                                                             Amount                   Attached
Earned Income (i.e., employment)
Unemployment Insurance
Supplemental Security Income (SSI)
Social Security Disability Income (SSDI)
Veteran's Disability Payment
Private disability insurance
Worker's Compensation
Temporary Assistance for Needed Families (TANF)
General Assistance
Retirement Income from Social Security
Veteran's Pension
Pension from a former job
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)
Veteran's Disability Payment
Private disability insurance
Worker's Compensation
Temporary Assistance for Needed Families (TANF)
General Assistance
Retirement Income from Social Security
Veteran's Pension
Pension from a former job
Child Support
Alimony or other spousal support
Other Source

             Total Monthly Income from all sources                            $0.00




    D:\Docstoc\Working\pdf\fb757dfb-d91e-45f1-a869-541e03c5be02.xls
                                               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):                        1

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         $534.00                     Family:         #DIV/0!          >         50%?                     #DIV/0!
Total Monthly
Cost                  $534.00
    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.




D:\Docstoc\Working\pdf\fb757dfb-d91e-45f1-a869-541e03c5be02.xls
                                                        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.
              Client/Household Income Past 30 days
                     Monthly Expenses                                              Month #1        Month #2
Rent
House/Apartment Security Deposit
Electricity
Electric Deposit
Heat
Water
Food/Hygeine/Household Items
Phone (cell phone or land line)
Child Care
Gas (for car)
Credit Cards (exclusive of food bill or other expenses paid
with credit card)
Car Insurance
Life Insurance
Cable
Internet
Bus tickets
Laudromat Washing & Drying
Monthly Child Support Payment (not child care)
Other Loans (car, personal)

Other Monthly Household Expenses not listed above (please
describe & provide monthly expense amount)




                                                   Total Monthly Expenses              $0.00        $0.00

                     Maximum HPRP DCA Allowed                                          $0.00         N/A

A negative number in the Maximum HPRP DCA Allowed indicates the remaining income the household should
have each month after expenses. Therefore, HPRP financial assistance cannot be used.


   D:\Docstoc\Working\pdf\fb757dfb-d91e-45f1-a869-541e03c5be02.xls
                                                             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 suport 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.

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




   D:\Docstoc\Working\pdf\fb757dfb-d91e-45f1-a869-541e03c5be02.xls
                              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.
   a)    The Landlord understands that the Tenant intends to obtain rental assistance from The
         Community Shelter Board ("CSB") through the Homelessness Prevention and Rapid Re-
         Housing Direct Client Assistance Program ("HPRP DCA").
   b)
         A housing inspection must be performed by CSB prior to the Tenant taking possession of
         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.
   c)    Rental assistance will be provided to Tenant by CSB only after successful completion of the
         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.
   D:\Docstoc\Working\pdf\fb757dfb-d91e-45f1-a869-541e03c5be02.xls   8 of 2
Client Name:               0
                                                                                    HPRP Homelessness Prevention
CSP #:                   0                                                          Client Eligibility Assessment
            Attach computation that total housing costs are at or below 50% monthly income.

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:




   D:\Docstoc\Working\pdf\fb757dfb-d91e-45f1-a869-541e03c5be02.xls   9 of 2
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).
         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.
            If not at or below 60% of monthly income, attach request for exception to this guideline and
            statement about how client will sustain housing.




                                                                     10 of 2
   D:\Docstoc\Working\pdf\fb757dfb-d91e-45f1-a869-541e03c5be02.xls
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:




                                                                     11 of 2
   D:\Docstoc\Working\pdf\fb757dfb-d91e-45f1-a869-541e03c5be02.xls
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:_________________

Employer representative to complete this section:

The person named above is employed by ______________________________________since
_______________. He/she is paid $______________ on a _____________basis and is currently working an
average of _____________hours per ____________.

Additional compensation please specify (if any):_________________________________________________
Probability of continued employment: ________________________________________________________

Authorized Employer Representative Signature: ________________________________Date:______________
Name, Title: _______________________________________________________________________________
Address and Phone: ________________________________________________________________________


           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 expected durationRepresentative Signature: is _____________________________.
basis. The Payment Source of the payments or benefits
_____________________________Date:____________
Name, Title: _______________________________________________________________________________
Address and Phone:
_________________________________________________________________________




D:\Docstoc\Working\pdf\fb757dfb-d91e-45f1-a869-541e03c5be02.xls
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.

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 _____________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: _____________________


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:___________________


D:\Docstoc\Working\pdf\fb757dfb-d91e-45f1-a869-541e03c5be02.xls
__________________




          D:\Docstoc\Working\pdf\fb757dfb-d91e-45f1-a869-541e03c5be02.xls
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.




D:\Docstoc\Working\pdf\fb757dfb-d91e-45f1-a869-541e03c5be02.xls
                                   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:                       (              )



Referring Agency Information

Case Manager:

Phone Number:                                (              )

Referring Agency:




D:\Docstoc\Working\pdf\fb757dfb-d91e-45f1-a869-541e03c5be02.xls
                                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:_________________


   D:\Docstoc\Working\pdf\fb757dfb-d91e-45f1-a869-541e03c5be02.xls
                                  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:




    D:\Docstoc\Working\pdf\fb757dfb-d91e-45f1-a869-541e03c5be02.xls
                                   Case Manager HPRP DCA Application Checklist

Client Name: 0                                                                      Provider Agency
                                                                                    0
CSP #          0

Supervisor Signed Application & all appropriate documentaiton:       YES            Expense Form      YES
Staff Affidavit Form:     YES
Prevention or Rapid Re-Housing Assessment Form:            YES
CPS Shelter Stay Printout, Signed Homelessness Certification or Self-Declaration of Housing Status Form:
CSP Referral Entered:                                                                                              YES
                            YES
Copy of I.D. for ALL adults in household:        YES

Check Request Form:
     _____ Agency Name                               _____   AMI % calculated/displayed
     _____ Client Name                               _____   HPRP DCA Request Number
     _____ Current Costs/Deposit/Arrearages          _____   CSP Number
     _____ Property & Lease Information              _____   Landlord Contact Information

Landlord Verification (must provide one of the following):
         _____ Verification of Prosepctive Housing Form or Signed Lease with Addendum
                  Note: A signed lease will be   The lease MUST contain the following information.
                  required before release of
                                                    _____ Dated within last 30 days
                  HPRP funds.
                                                    _____ Client Name                _____ Addendum Form
                                                    _____ Unit Address
If at risk of losing housing, must provide:         _____ Rent/Deposit Amounts
                                                    _____ Signed by Landlord & Client
         _____ Eviction notice
                                                    _____ Landlord contact information (address/phone number)
                                                    _____ Matches check request
                                                    _____ Length of lease identified
Property Ownership:
      _____ Attached a printout of property ownership from Auditor's website AND one of the following:
                    _____ W-9 (if vendor is an individual need social security number ; if vendor is a corporation need EIN )
                               _____ on file at CSB
                          Property Management Agreement or other legal document if vendor is different than Owner
                    _____ listed on the Auditor's website

Utility (must contain the following information):

      _____ Client Name                    _____ Account Number                         _____ Matches Check Request
      _____ Amount Owed                    _____ Utility Company Information            _____ Time Period of Request

Income Verification
        _____ Income Sources Form AND
        _____ Check and attach one of the following. Income standards, in order of preference per HUD.
                        Third Party Documentation (e.g., pay stub, benefit statement, etc.) in accordance with the
              _____
                        HPRP DCA Policies and Procedures (preferred verification, per HUD)
              _____     Verification of Income Form (completed by employer)
              _____     Oral Verification of Income Form (completed by case manager)
              _____     Self-Declaration of Income Form (completed by case manager)

Income Calculation (pay stubs or employment verification letter):
# ________ Hours worked/week x $___________/hour x 52 weeks ÷ 12 months = $_____________ monthly income

Client Signature Form      with ALL appropriate signatures      YES
                                Furniture Bank of Central Ohio Request



Name (Last, First MI): 0                                                 CSP #      0
       Address & Street: 0
                               City: 0                                   State OH
                     Zip Code: 00000




Client Signature


Case Worker Name


Case Worker Signature


Date


Agency Provider                                                   0




D:\Docstoc\Working\pdf\fb757dfb-d91e-45f1-a869-541e03c5be02.xls
                                 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




D:\Docstoc\Working\pdf\fb757dfb-d91e-45f1-a869-541e03c5be02.xls
Family Size                             1 Person          2 People 3 People 4 People 5 People 6 People 7 People 8 People

Very Low Income (50%)                        $24,000          $27,450   $30,850   $34,300   $37,050   $39,800   $42,550   $45,300



    Median Income                            $48,000          $54,900   $61,700   $68,600   $74,100   $79,600   $85,100   $90,600


2009 Median 4 Person Family Income $68,600
Effective March 19, 2009


Note:
Income limits are revised periodically
The must current limites are available on the internet at:
http://www.huduser.org/datasets/il.html




D:\Docstoc\Working\pdf\fb757dfb-d91e-45f1-a869-541e03c5be02.xls
                     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:


D:\Docstoc\Working\pdf\fb757dfb-d91e-45f1-a869-541e03c5be02.xls

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:85
posted:7/27/2011
language:English
pages:23
Description: Property Checklist Landlord Tenant document sample