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Emergency Services & Housing Assistance Program 2016

MaineHousing Rental Subsidies Process Guide

Table of Contents

Stability Through Engagement Program (STEP) Process………………..2

STEP Application…………………………………………………………………………………..2

STEP Coupon Issuance & Briefing………………………………………………………….2

STEP Security & Utility Deposits……………………………………………………………3

STEP Move in and Lease up……………………………………………………………………3

STEP Program Completion……………………………………………………………………5

Housing Choice Vouchers (HCV) Process & Overview……………………..6

Monitoring………………………………………………………………………………………8

Maine Housing Contacts………………………………………………………………….9

Supporting Documents…………………………………………………………………..10

Client File Checklist………………………………………………………………………………11

Housing Status Documentation Table…………………………………………………..12

STEP Coupon Issuance Briefing Guidance…………………………………………….17

End of Participation Sub assessment…………………………………………………….21

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Stability through Engagement Program (STEP) Process

STEP Application

1. Complete the STEP Application Packet which includes; the STEP Application, STEP Authorization for Release of Information; and the DHHS Release forms (see Attached: STEP Application Packet);

2. Enter client information in HMIS & upload in Service Point or upload in ShareFile for non-HMIS participating agencies.

3. Inform the Program Officer via email of the clients Service Point ID or Sharefile file name. The Program Officer will review the application and run the necessary background checks.

4. The Program Officer will inform the Navigator if the client meets eligibility and if so, the Navigator can proceed to a Coupon Issuance Briefing (see Attachment:: STEP Coupon Issuance Guidance Document).

5. If the client is ineligible the Program Officer will issue a denial letter that will be sent by the Navigator and kept in the clients file. The client will have the opportunity to appeal this decision.

6. The client file will be updated and the paper file will be organized according to the Client File Checklist.

7. Enter all required data and the STEP assessment into HMIS or comparable database. (See HMIS Data Entry Manual)

STEP Coupon Issuance and Client Briefing

When a client has been found eligible for STEP, the Navigator will conduct a Coupon Issuance Briefing (Briefing). A Briefing involves reviewing program rules, requirements and expectations. The Navigator will review all the documents in the Briefing Packet with the Participant and will obtain signatures and other pertinent information on several documents with the Participant. Each document will be explained in detail. When the briefing has been completed the Participant will retain the Briefing Packet with copies of the documents that have been completed.

The Navigator will upload the following to HMIS or ShareFile:

STEP Coupon Updated income documentation

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The Coupon Issuance Briefing Packet consists of the following (items with an * will be kept in the clients file):

Obligations While in the STEP program* STEP Coupon * Payment Standards Utility Allowances Key steps to using your STEP Coupon Landlord Packet:

Landlord letter Program Summary Request for Unit Approval Lease Addendum Lead Based Paint Disclosure Form Radon Disclosure W-9

A Good place to live Protect Your Family from Lead in Your Home Fair Housing Bed Bugs Fact Sheet Radon in Rental Housing Are you a Victim of Housing Discrimination? Employment Verification Form* Certification of Zero Income Form*

STEP Security & Utility Deposits

The Program may provide a security and utility deposit to assist participants in securing housing. The maximum amount provided will be a one-time utility deposit and a security deposit no greater than one month’s rent. Utility deposit assistance may be used only for utilities permitted under the Section 8 utility allowances, which include electricity, gas, sewer and water, but do not include telephone and cable television. A utility deposit may be provided under the STEP Program only if;

1. The tenant family has been issued a rental assistance coupon and;2. The unit selected by the tenant family has passed inspection, and 3. The tenant Family has entered into a lease with the owner.

Documentation from the utility company will be necessary in order to receive the utility deposit.

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STEP Move-in and Lease Up

1. Submitting the Request for Unit Approval (RFUA):

The Navigator receives the following completed documents from the landlord and tenant:

RFUA Lease Addendum Lead Base Paint Disclosure Form Maine Radon Gas Disclosure Statement W-9 Sample Lease

The Navigator will review each item for completeness, ensuring they meet program requirements, this includes;

Ensuring the rent does not exceed Fair Market Rent (FMR) including reviewing utility sheets to ensure that total rent =contract rent + utility allowance.

Determining if total rent is within payment standards for the coupon issued to the household. .

Determining if the paperwork is: Incomplete or does not meet program requirements: Too expensive Lease is disagreeable to the client…

…If any of these occur then the Navigator will contact the landlord and/or tenant to negotiate.

Once this review is completed Navigators will submit the paperwork to the Program Officer through ServicePoint or ShareFile for non-HMIS participating agencies.

2. Once the Program Officer receives and reviews the RFUA The Program Officer will set up an appointment to inspect the unit. The participant or participant representative and/or landlord, or landlord representative, is required to be present at the inspection. When inspection is complete the Program Officer will inform the landlord and applicant of PASS or FAIL status.

o IF THE UNIT IS A PASS: The Navigator must clarify what date the tenant will be moving in to determine the effective date of the lease and the beginning of rental assistance payments. The Navigator will also need to provide updated income information and updated homelessness status documentation at this time.

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o IF THE UNIT IS AFAIL: The Program Officer will inform landlord and applicant of what deficiencies must be corrected.

IF THE UNIT IS A FAIL and the landlord is:

Agreeable to correcting the deficiencies: The Program Officer will schedule a re-inspection or otherwise verify that the deficient items have been corrected and follow procedures (above) for a PASS inspection.

Disagreeable to correcting the deficiencies: The Program Officer will inform the Navigator applicant of the landlord’s decision and the need to obtain up a new landlord packet to start searching for a different unit.

3. Completing the Move in: When the unit has passed and the participants are ready to move in the Navigator MUST provide the;

Lease-up date Current homeless documentation Current income verifications from income sources.

Current verifications must include all income sources and be dated within 60 days prior to the move in date.

With this information the Financial Program Officer will create the Landlord Lease Letter, indicating any additional paperwork that is needed from the landlord, (typically a copy of the executed lease and Housing Assistance Payment (HAP) Contract) and what the tenant payment to landlord and MaineHousing payment to landlord is. This letter will be sent to the Landlord, Tenant, and Navigator. Checks are mailed from MaineHousing the first week of the month.

Program Completion

The maximum term of STEP Coupon Assistance is 12 months. At any time that the STEP funding is no longer necessary, or the participant is no longer eligible within those 12 months, the STEP funding can cease. In these cases Landlords will be given a minimum of 30 days notice.

When clients end participation with the STEP program Navigators service providers must submit a STEP End of Participation (EOP) Document. The information on the form is required. It will need to be completed and returned to your Program Officer.

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Housing Choice Voucher (HCV) Process and Overview

Housing Choice Vouchers will be administered by MaineHousing’s HCV Department according to federal regulations and MaineHousing policies detailed in the most recent Administrative Plan for Section 8 Housing Choice Voucher and Project Based Voucher Programs. The Administrative Plan is available on the MaineHousing website at the following link:

http://www.mainehousing.org/programs-services/rental/rentaldetail/HousingChoiceVouchers

Grantees will be required to screen potential applicants and make referrals to the HCV Department for those vouchers available to the grantee. Eligibility for the HCV Program includes but is not limited to the following criteria. The applicant family must:

o Qualify as homeless at the time of application.

o Qualify as a family as defined by HUD and MaineHousing.

o Have income that does not exceed 50 percent of the median income for the area, adjusted for family size.

o Qualify on the basis of citizenship or the eligible immigrant status of family members.

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o Provide social security number information for household members as required.

o Consent to MaineHousing’s collection and use of family information as provided for in MaineHousing-provided consent forms.

MaineHousing makes the final decision on program eligibility, which requires a determination that the current or past behavior of household members does not include activities which are prohibited by HUD or MaineHousing. Upon admission, each family will be required to pay up to 40% of their adjusted monthly household income for rent each month.

To access the available HCV rental assistance, the following criteria must be met:

1. Rental subsidies must be for permanent housing. Emergency, temporary or transitional housing is not eligible for rental assistance.

2. The rental assistance must be for a residence located within MaineHousing’s area of operations which is defined as any municipality that is not served by a local housing authority. Applicants may not reside in a town that has its own Public Housing Authority.

HCV Security Deposit Program

The Security Deposit Program will be offered to first time Housing Choice Voucher applicants currently being served who are searching for a new unit within MaineHousing’s jurisdiction. We can assist with up to $500 towards a security deposit for new admissions only.

Roles & Expectations

Specialized Program Officer

MaineHousing’s HCV Department will assign a Home to Stay Specialized Program Officer to each grantee. This individual will serve as the single point of contact for that grantee for all questions, referrals and necessary follow-up. The Home to Stay Specialized Program Officer will ensure that each grantee receives:

An orientation to the HCV program guidelines and procedures, including tenant and landlord responsibilities.

An invitation to observe a tenant briefing. All HCV program newsletter and program change announcements.

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The Home to Stay Program Officer will also provide the following services: Make a final determination as to whether the applicant is eligible for

the HCV program. Conduct the tenant briefing, which will include voucher issuance. Assist the client in the housing search. Review and approve the Request for Tenancy Approval once a unit is

located. Order an HQS inspection and provide any necessary follow-up. Assist in understanding all tasks required of the tenant necessary to

maintaining the voucher in good standing.

Monitoring

MaineHousing is responsible for compliance monitoring to verify that funds administered by sub-grantees are expended in accordance with Program rules and Federal requirements. Grantees will be monitored on site or by teleconferencing by their assigned Homeless Initiatives Program Officer.

Monitoring reviews for Program components may include but are not limited to; client files, program administration policies and procedures for intake, assessments, Housing Stability Plans, financial administration and data collection

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components of the Program. Program monitoring will also include periodic reviews of HMIS data completeness and quality on a monthly and quarterly basis.

MaineHousing staff will also provide grantees with on-going technical assistance and training on the Program rules and regulations, as needed. MaineHousing will review the performance of each grantee in carrying out its responsibilities whenever determined necessary by MaineHousing.

In conducting program reviews, MaineHousing will rely primarily on information obtained from the records and reports from the grantee, as well as information from onsite monitoring, audit reports, and information from HMIS.

MaineHousing Contacts

Scott Tibbitts

Homeless Initiatives Program Officer

[email protected]

(207) 626-4604

Leah Bruns

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[email protected]

(207) 626-4677

Rob Parritt


[email protected]

(207)624-5703

Rich Diversi

Homeless Initiatives Financial Program Officer

[email protected]

Phone:(207) 626-4604

Megan Spencer

Homeless Information Resource Officer

[email protected]

(207) 624-5783

Kelly Watson

Homeless Information Resource Officer

[email protected]

(207)624-5742

Housing Choice Voucher (HCV) Program

Logan McNeill

HCV Program Officer

[email protected]

Phone: 207-624-5733

Fax: 207-624-5713

Supporting Documents

STEP Application Packet

STEP Coupon

STEP Coupon Issuance Guidance

STEP End of Participation Document

STEP Admin Plan

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mailto:[email protected]



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CLIENT FILE CHECKLIST

Client Name: _______________________

Name of Document Check if Present & Complete

Missing & or Incomplete

Comments

Intake & Assessment Documents

1 HMIS Release of Information

2 Homeless Verification3 VI-SPDAT4 Housing Stability Plan(s) in

chronological order5 Miscellaneous

STEP Program Documents

1 STEP Application2 STEP Authorization for

Release of Information3 Income Verification(s)4 DHHS Match Form5 Declaration 214 (s)6 Social Security Cards and

Identification7 STEP Coupon8 STEP Obligation Sheet9 Additional Correspondence

(Emails etc.)10

Additional rental information correspondence and or EOP or Termination Letters if applicable

11

Initial Rental Assistance Payment Letter

12

Lease Amendment letter (s) &Rent Change letter(s) in chronological order) if applicable

13

Miscellaneous

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Comments: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________ _____________________Name/Title of Person Completing Monitoring Date

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Housing Status Documentation Table

Living Situation Homeless per ESG Criteria?Acceptable Types of Documentation (in

order of preference)Documentation Standard

Sleeping in an Emergency Shelter

Yes HMIS record of stay Obtain HMIS record showing shelter entry date and stays. Include HMIS record in participant file

OR(if HMIS record cannot be obtained)

Homeless certification Obtain signed and dated original Homeless Certification from shelter provider. A Homeless Certification is a standardized form that, as a minimum, contains the following:o Name of the shelter programo Statement verifying current shelter occupancy of applicanto Signed and dated by authorized shelter provider representative

Include Homeless Certification in participant file.

OR(if HMIS record and Homeless Certification cannot be obtained)

Emergency shelter provider letter

Obtain letter from emergency shelter provider.Letter Must:

o Be on shelter provider letterheado Identify shelter programo Include statement verifying current shelter occupancy of

applicant, including most recent entry dateo Be signed and dated by shelter provider

Include emergency shelter provider letter in participant file

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Place Not Meant for Human Habitation (e.g., cars, parks, abandoned buildings, streets/sidewalks)

Yes Homeless certification Obtain signed and dated original Homeless Certification authorized entity. A Homeless Certification is a standardized form that, at a minimum contains:o Name of the authorized entityo Statement verifying current living situation of applicanto Signed and dated by authorized entity representativeo Include Homeless Certification in participant file

OR(if Homeless Certification cannot be obtained)

Referral source letter. Obtain letter from referral source (e.g. local law enforcement agency)

Letter must:o Be on referral agency letterheado Identify referral agencyo Include a statement verifying the current homeless status

of the applicanto Be signed and dated by referral agency

Include letter in participant file

AND

Self-declaration of homelessness

Obtain a signed and dated original self-declaration of homelessness from applicant

Navigator must document attempt to obtain written third party verification and sign self-declaration form

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Include completed self-declaration form in participant file



Hospital or Other Institution

Yes, if also meet two conditions:

1. Stay in hospital or other institution has been for 90 days or less.

AND

2. Was sleeping in an emergency shelter or other place not meant for human habitation (cars, parks, streets, etc.) immediately prior to entry into the hospital or institution.

Letter from hospital or other institution.

Obtain letter from hospital or other institutionLetter must:

o Be on hospital or other institution letterheado Include a statement verifying the current hospital/institution

stay of the applicanto Include hospital/institution admission and discharge dates

verifying that stay has been 90 days or less.o Be signed and dated by hospital/institution

Include letter in participant file

AND(to verify homeless status prior to hospital or other institution admission)

HMIS record of shelter stay (if previously sleeping in emergency shelter).

Obtain HMIS record showing shelter entry date and stays. HMIS record must indicate shelter stay immediately prior to (i.e. the

day before or same day as )hospital/institution admission date Include HMIS record in participant file

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Hospital or Other Institution

OR(If HMIS record cannot be obtained)

Homeless certification Obtain signed and dated original Homeless Certification from shelter provider or authorized entity

Certification must verify homelessness (residing in shelter or place not meant for human habitation) immediately prior to (i.e. the day before or same day as) hospital/institution admission date

Include Homeless Certification in participant file

OR(If HMIS record or Homeless Certification cannot be obtained)

Emergency shelter provider or referral source letter (if previously sleeping in emergency shelter or place not meant for human habitation

Obtain emergency shelter provider or referral source letterLetter must:

o Be on shelter provider or referral source letterheado Include shelter programo Include statement verifying shelter stay or observed homeless

occurrence immediately prior to (i.e. the day before or same day as) hospital/institution admission date

o Be signed and dated by shelter provider Include letter in participant file

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(continued)

AND


Obtain a signed and dated original self-declaration of homelessness from applicant

Self-declaration must verify homelessness (residing in shelter or place not meant for human habitation immediately prior to (i.e. the day before or same day as) hospital/institution admission date

Navigator must document attempt to obtain written third party verification and sign self-declaration form

Include completed self-declaration form in participant file

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Transitional Housing

Yes, if graduating from or timing out of a Transitional Housing Program

Homeless certification

Obtain signed and dated original Homeless Certification from transitional housing provider. A Homeless Certification is a standardized form that, at a minimum contains:o Name of the transitional housing programo Statement verifying current transitional housing occupancy of

applicanto Statement verifying the applicant is graduating from or timing out

of the transitional housing programo Statement verifying the applicant was residing in emergency

shelter or place not meant for human habitation immediately prior to transitional housing admission

o Signed and dated by authorized transitional housing provider representative

Include Homeless Certification in participant file



Domestic Violence

Yes, if applicant is fleeing or attempting to flee domestic violence, dating violence, sexual assault, stalking, or other dangerous or life threatening conditions in the applicant or family’s current housing situation including where the health and safety of children are jeopardized and who have no other residence and lack the resources or support networks to obtain other permanent housing.


Obtain a signed and dated original self-declaration from applicant Navigator must document attempt to obtain written third party

verification and sign self-declaration form Include completed self-declaration form in participant file

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Stability Through Engagement Program (STEP) Briefing Packet Guidance: When a client has been found eligible for STEP, Navigators will conduct a Coupon Issuance Briefing (Briefing). A Briefing involves reviewing program rules, requirements and expectations. The Navigator will review all the documents in the Briefing Packet with the Participant and will obtain signatures and other pertinent information on several documents with the Participant. Each document will be explained in detail, when completed the Participant will retain the Briefing Packet with copies of documents that have been completed.

Form: General Description: Once Completed…:

Obligations While in the STEP program

Review this entire document with the participants. This is an outline of obligations that they are required to fulfill in order to receive STEP rental assistance. Failure to comply with any of the listed obligations could result in the loss of rental assistance.

One copy for the participant

Original for the participants file

STEP Coupon This document outlines all of the rules, requirements and obligations of the household who is participating in the program. Although several of the requirements are outlined in the “Obligations Sheet” the detailed requirements included in the STEP Coupon should be discussed with the client.The STEP Coupon outlines: The size of the unit the household has been approved for Signatures of the Head of Household and the Navigator The dates in which the document is valid; Issuance and Expiration**Coupons expire 90 days after Issuance. The Participant must submit a request for an extension for an additional 30 days in writing at least seven days before the expiration date on the Coupon. Authorization for an extension must be approved before the expiration of the Coupon or any extension. Before the 120th day, if a request is made in writing, MaineHousing may grant another extension of 30 days as a reasonable

One for the participant

One for the participants file

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accommodation for families with a member who is disabled and needs an accessible Unit.

Payment Standard Schedule

Payment standards are used to calculate the housing assistance payment (HAP) that MaineHousing pays to the owner on behalf of the family leasing the unit and is based upon bedroom size. The range of possible payment standard amounts is based on HUD’s published fair market rent (FMR) schedule for the FMR area in which MaineHousing has jurisdiction. FMRs are based on either the 40th or 50th percentile of rents charged for standard rental housing in the FMR area. Payments Standards are usually revised annually around October 1.The Navigator must explain how the Payment Standard Schedule works with the Participant. The amount listed on the Payment Standard Schedule includes the amount it will cost for both rent and utilities.How to use the Payment Standard Schedule: Reference the bedroom size of the unit and cross reference to the area

in which the unit is located. Calculate the Contract Rent amount with the established utility

allowance amount. Both items added together must not exceed the Payment Standard amount.

Emphasize to the Participant that the point here is NOT to maximize the value of the coupon, but to give to them a better understanding of the program guidelines. They should look for a unit that they will reasonably be able to afford on their own when their participation in the program ends.

For the Navigator

Utility Allowance Charts

Utility allowances are estimates of the expenses associated with different types of utilities and their uses. The utilities for which allowances may be provided include electricity, natural gas, propane, fuel oil, wood or coal, and water and sewage service, as well as garbage collection. The functions, or end-uses, covered by an allowance may include space heating, water heating, cooling, refrigeration, lighting, or appliances. Allowances are not provided for telephone service. Utility allowances can be small or large, ranging from less than $10 to over

For the Navigator

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$200 for a resident household per month, depending on the Housing Authority, the number of utilities and uses covered, and the dwelling unit and/or household size.

How to use the Utility Allowance (UA) Charts: Find the town in which the unit is located on the Utility Allowance

Master List Reference the UA Chart appropriate for the type of building the unit is

located in. For example: Low Rise, Walk Up, Single Family etc. Referencing the bedroom size of the unit and cross reference each

type of utility that the client will be responsible for i.e. Cooking: Electric, Other Electric

Calculate the total Add the UA amount to the Contract Rent amount to determine the

Total Rent

The UA added to the Contract Rent must not exceed the Payment Standard.

Keys Step to Using Your STEP Coupon

This document was created to assist a client with the process of using their STEP coupon.It outlines how to go about getting a unit inspected and approved.

For the participant

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Landlord Packet:

The Landlord Packet contains all of the documents that are required to be completed in order to request a Housing Quality Standards (HQS) inspection. The information in the documents must be agreed upon by both the landlord and the Participant and then submitted to the Navigator for review. Once the Navigator determines that the unit meets program guidelines the documents must be uploaded to Service Point or ShareFile.The Landlord Packet contains: Landlord letter Program Summary Request for Unit Approval Lease Addendum Lead Based Paint Disclosure Radon Gas Disclosure W-9

For the participant to submit to a potential landlord and return to the Navigator

Landlord letter The landlord letter outlines the documents that must be completed to initiate a HQS Inspection. It explains that normal tenant screening practices should take place; that the tenant should not sign the lease or move into the unit before the unit has passed HQS and that MaineHousing will contact them to arrange for an inspection once the paperwork is received and approved.

For the potential landlord.

Program Summary

The program summary outlines STEP in detail for the landlord. The document reviews information about Income Eligibility/Length of assistance, security and utility deposits etc.

For the potential landlord.

Request for Unit Approval

The Request for Unit Approval is completed by the landlord, the Participant, and the Navigator.The document outlines details of the unit; monthly rent, security deposit, & utility responsibility. The Participant will fill in their name and contact phone number at the

top, sign & date. The Landlord will complete the rest of the form, except the grey

For the potential landlord and return to the Navigator to complete.

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sections, sign & date. The Navigator will review the form, complete the grey sections, verify

that the unit is of appropriate size, and that the rent and utility costs are within program guidelines.

Lease Addendum

The Lease Addendum will be attached to the executed lease. It is included in the landlord packet to allow the landlord to review what will be added to their lease document. The Lease Addendum outlines the requirements and expectations for landlord to participate in STEP. Must be signed by both the landlord and the Participant

For the potential landlord and return to the Navigator

Lead Based Paint Disclosure

The Lead Based Paint Disclosure informs the Participant of known presence of lead in the building being considered for rental

Must be completed and signed by both landlord and Participant


Radon Gas Disclosure

The Radon Gas Disclosure informs the Participant of the levels of Radon Gas in the building being considered for rental. Must be completed and signed by both landlord and Participant


W-9 The W-9 is completed for income tax purposes. Information on the document allows MaineHousing to inform the IRS of monies released to the landlord.

Must be completed and signed by the landlord


A Good Place to Live

This document was created to assist a client with the knowing some of the things to look for when viewing apartments as related to HQS. It is not a comprehensive listing of HQS requirements but contains general information of what to look for in terms of safety.

For the participant

Protect Your Family from Lead in Your Home

This comprehensive document outlines the details of Lead Paint dangers; what to look for and how to protect oneself from the dangers of Lead Paint.

For the participant

Fair Housing Equal

These documents discuss the Fair Housing Act and contain information on how to submit a claim if a person feels their rights have been violated

For the participant

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Opportunity for All & Are you a Victim of Housing Discrimination

or they have been discriminated against.

Bed Bugs Fact Sheet

Because bed bugs have become an issue in the last few years this document is included as an educational tool in the briefing packet. Bed Bug biology, prevention and control are discussed.

For the participant

Employment Verification Form/Other Income Verifications

The Navigator is required to send out Income Verifications directly to income sources for any household members who have income. The form SHOULD NOT be given to the Participant to deliver but should be sent directly to the source.Certification of Zero Income FormIf there is no income a Certification of Zero Income is required to be completed on a MONTHLY basis by all adult household members.AT COUPON ISSUANCE the Navigator must obtain income verifications and/or Certification of Zero Income forms. If it is more than 30 days before the Participant leases up, the Navigator must again obtain income verifications and/or Certification of Zero Income AT LEASE UP.

For the Navigator

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**PLEASE COMPLETE THE FOLLOWING FORM FOR EACH ADULT HOUSEHOLD MEMBER WHO HAS EXITED THE STEP PROGRAM. ONCE COMPLETED, UPLOAD THIS DOCUMENT TO SERVICEPOINT AND NOTIFY YOUR PROGRAM OFFICER ONCE COMPLETED.

ServicePoint Client ID (if applicable): ___________________________

EOP Date: ______/_______/_________

First Name: MI: Last Name: _______________________________ Suffix: ___________

Head of Household: Yes No

Reason for Leaving: Left for housing opp. before completing program: Completed program: Non-Payment of rent / occupancy charge: Non-Compliance with program Criminal activity / destruction of property / violence Reached maximum time allowed Needs could not be met: Disagreement with rules/persons Death Unknown/Disappeared Other (Specify) ____________________________________________________________________

Destination or residence at program exit:

(choose one) Deceased Rental by Client with GPD TIP Subsidy Emergency Shelter Rental by Client with Other Ongoing Housing Subsidy

(Non-VASH) Foster Care Home or Foster Care Group Home Residential Project or Halfway House with no

Homeless Criteria Hospital or other Residential Non-Psychiatric Medical Facility

Safe Haven

Hotel or Motel Paid for without an Emergency Shelter Voucher

Staying or Living with Family, permanent tenure

Jail, Prison or Juvenile Detention Facility Staying or Living with Family, temporary tenure Long-Term Care Facility or Nursing Home Staying or Living with Friends, permanent tenure Moved from one HOPWA funded project to HOPWA PH

Staying or Living with Friends, temporary tenure

Moved from one HOPWA funded project to HOPWA TH

Substance Abuse Treatment Facility or Detox Center

Owned by Client, No Ongoing Housing Subsidy Transitional Housing for Homeless Persons (includes homeless youth)

Owned by Client, with Ongoing Housing Subsidy Other (specify)__________________________________________

Permanent Housing for Formerly Homeless Persons

No Exit Interview Completed

Place Not Meant for Habitation Client Doesn’t Know Psychiatric Hospital or Other Psychiatric Facility Client Refused Rental by Client, No Ongoing Housing Subsidy Data Not Collected Rental by Client with VASH Subsidy

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For households with children, if any of the associated minor household members went to a different destination than the Head of Household, please indicate the household member’s name and exit destination below.

________________________________________ _______________________________________________

________________________________________ _______________________________________________

________________________________________ _______________________________________________

Receiving Income from any source? Yes No Client Doesn’t Know Client Refused Data Not Collected

Receiving Income

Source of Income (Check all that apply)

Income Amount

Yes No Earned Income $

Yes No Unemployment Insurance $

Yes No Supplemental Security Income (SSI) $

Yes No Social Security Disability Income (SSDI)

$

Yes No VA Service Connected Disability Compensation

$

Yes No Private Disability Insurance $

Yes No Worker’s Compensation $

Yes No Temporary Assistance for Needy Families (TANF)

$

Yes No General Assistance $

Yes No Retirement Income From Social Security

$

Yes No VA Non-Service Connected Disability Pension

$

Yes No Pension or Retirement Income from Another Job

$

Yes No Child Support $

Yes No Alimony or Other Spousal Support $

Yes No Other – Specify Source _____________________

$

Receiving Non-Cash Benefit from any source? Yes No Client Doesn’t Know Client Refused Data Not Collected

Receiving Benefit

Source of Non-Cash Benefit (Check all that apply) Benefit Amount(when applicable)

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Yes No Supplemental Nutrition Assistance Program (SNAP – Food Stamps)

$

Yes No Special Supplemental Nutrition Program for Women, Infants and Children (WIC)

$

Yes No TANF Child Care services $

Yes No TANF transportation services $

Yes No Other TANF-funded services $

Yes No Section 8, public housing, or other ongoing rental assistance $

Yes No Temporary Rental Assistance $

Yes No Other Source – Specify Source _____________________________________

$

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