Housing First Forms Flashcards
Authorization for Release of Information
Signing this gives us permission to obtain any info needed for you to participate in this program.
Staff Certification of Eligibility for HPRP 2 Assistance
Only for the CM to sign. It states the following:
(1) client meets criteria
(2) based on true or complete info
(3) neither the staff member or supervisor are related to client or have any business or personal dealings.
(4) no one will benefit financially from this eligibility determination
Self Declaration of income
Signing to state that the income documented on this sheet is the only income that you are receiving and that it is correct.
Declaration of Citizenship
By signing this form you declare that you are a citizen of the USA.
Write your name. Check I am a citizen and sign
Sign for minors
Homeless Third Prty Verification
Client has to get an organization to sign as proof of homelessness. Case manager to verify that you are indeed homeless. If staying in someone’s home, it should be notarized.
Client Contract
(1) this is not an agreement to pay any funds to the landlord.
(2) assistance to this household is based on information provide on or before the signed date.
(3) only ppl listed on app will reside at the dwelling; if household income changes the household must notify the program
Client Contract part 2
(4) the applicant states that he/she is homeless and has exhausted all other resources
(5) if client violates contract program will deny payment
(6) The family budget was discussed. The program will not assist the household in a housing unit above this cost
Tenant Info Form
FRONT
States who all lives in the household
BACK
Ask questions regarding drugs, shelter, criminal history, etc.
Tenant info prt 2
Prt 5: income and its source
Prt 6: child care expenses
Prt 7: only for head of household that are 62 years older or disables
Certification of Rent Reasonableness
Gives the client a criteria to compare to find suitable housing that fits the budget rent
Notice of Privacy Practice
Stating that you received a copy of the HIPAA law, as required by law.
Client Rights & Responsibilities
This sheet identify what you should expect from us and what we should expect from you. Your entitled to Respect, considerate Professional, private, confidential service. Your entitled to be treated with respect and given professional and confidential service. Your right to be respected and given professional and courtesy service. If you don’t feel you have gotten that service here is the grievance procedure.
NJHMIS client consent form
Homeless Management Information System. 2 levels of information sharing. The last choice doesn’t give us permission to put your info into the system. If you chose that one then will automatically be ineligible. We put your information in the system to see if. We put your info into the system to document the services we have given you.
How to do the budget?
Find the average of the gross and the net income separately
If client gets paid bi-weekly multiply by 26
If client gets paid weekly multiply by 52
Than / by 12 to get monthly income
