CoC Rapid Rehousing Application

CoC Rapid Rehousing Program Application

Metro Dallas Homeless Alliance HMIS Privacy Notice
This Organization provides services for individuals and families at-risk of or experiencing homelessness. This Organization participates in the MDHA Homeless Management Information System (HMIS) and/or Coordinated Access System (CAS). The MDHA HMIS is used to collect basic information about clients receiving services from this Organization. This requirement was enacted to get a more accurate count of individuals and families experiencing homelessness, and to identify the need for different services. The MDHA CAS is used to connect individuals and families at-risk of or experiencing homelessness to the services they need. The HMIS is required by the US Department of Housing and Urban Development (HUD) for agencies that receive HUD funding. HMIS is not electronically connected to HUD and is only used to share information by local authorized agencies. This Organization only collects information that is considered appropriate and necessary. The collection and use of all personal information are guided by strict standards of privacy and security. This Organization may use or disclose information from the MDHA HMIS and/or the MDHA CAS under the following circumstances: • To provide or coordinate services for an individual or household; • For functions related to payment or reimbursement for services; • To carry out administrative functions; • When required by law; • For research and/or evaluation; • For creating de-identified data; or • To prevent or lessen a serious and imminent threat to the health or safety of an individual or the public in general A copy of the MDHA CoC Privacy Policy, describing allowable uses and disclosures of data collected for the purposes of the MDHA HMIS and/or the MDHA CAS, is available to all clients upon request. This privacy notice and the privacy policy may be amended at any time and those amendments may affect information obtained by the organization before the date of the change. Public Notice (Federal Register / Vol. 69, No. 146) / Effective August 30, 2004
Applicant Information
Applicant Name:*
First Last
Today's Date:*
MM slash DD slash YYYY
Temporary Address:*
Street Address Address Line 2 City State ZIP Code
County:*
Highest Grade Completed:*
Contact Phone:*
Work Phone:
Applicant Email Address:*
Social Security Number:*
Birthdate:*
MM slash DD slash YYYY
Age:*
Recent living situation:*
- Homeless from the streets
- Homeless from emergency shelter
- Transitional housing
- Psychiatric Facility
- Substance abuse treatment facility
- Hospital or other medical facility
Ethnicity:*
- Hispanic
- Non-Hispanic
Race:*
- White
- Black
- Asian
- American Indian/Alaskan Native
- Native Hawaiian/Other Pacific Islander
- Black & White
- Asian & White
- American Indian & White
- American Indian & Black
- Other Multi-Racial
Marital Status:*
- Never married
- Married
- Divorced
- Widowed
- Separated
U.S. Citizen?*
- Yes
- No
Veteran?*
- Yes
- No
Pregnant?*
- Yes
- No
Due Date:
MM slash DD slash YYYY
Household Information: List all other persons who live with you (list Head of Household first). If any of the persons living with you is not a member of your family* and is simply a roommate or live-in attendant, please indicate this in the relationship blank. (Note that this designation cannot be changed in the future.)*
Last Name, First Name, MI Relationship to You DOB Sex Veteran? Y or N Race Highest Grade Completed
Family means persons who are related to you, and includes persons living with you who are determined to be important to your care and well-being.*
Family Member Wages/Salaries Benefits/Pensions Public Assistance Other Income Asset Income
Do you have medical expenses not covered by insurance?*
- Yes
- No
Are your dependents in child care?*
- Yes
- No
- N/A
Have you or any one else in your household applied for SSI or Social Security benefits and been denied?*
- Yes
- No
Date of most recent application:
MM slash DD slash YYYY
Do you have a checking or savings account, stocks, bonds, etc?*
- Yes
- No
Amount:
Car License #:
Car make/Model/Year:
Do you or any member of your household have limitations due to health, age, or other conditions?*
- Yes
- No
Please specify:
Are you currently on probation or parole?*
- Yes
- No
Parole Officer Name:
Parole Officer Contact Number:
Do you or any member of your household require special housing accommodations? (i.e., downstairs, bus line, ramp, handrails, etc)*
- Yes
- No
Please specify:
Have you or any member of your family over the age of 15 been convicted of a crime?*
- Yes
- No
When?
Where?
Have you lived in federally subsidized housing before?*
- Yes
- No
Where?
Are you receiving assistance from any other Social Service Agency?*
- Yes
- No
Please list below.
Agency Service Case Manager Phone
Please list any credit cards, time payment, or other debts you or other household members have.
Name Amount
Are you or any member 18 or older currently a student or attending a job-training program?*
- Yes
- No
Please describe below.
Do you have any pets?*
- Yes
- No
Type and number:
Note
You may at this or any time during your tenancy request reasonable accommodation for a handicap or disability of a household member to the extent necessary so that all family members can meet lease requirements or other requirements of tenancy.
Acknowledgment of Receipt*
I, the Applicant, acknowledge receipt of the following documents, which are provided to me in connection with my application for assistance: • Client Rights and Responsibilities (includes grievance process) • Statement of Confidentiality/Authorization to Release Information
Applicant Certification:*
I, THE APPLICANT, CERTIFY AND ACKNOWLEDGE THAT: • The information, provided on this Application and Worksheets (which are part of this Application) and used to determine my eligibility and amount of assistance, is true and correct to the best of my knowledge and belief. This information is subject to verification, and falsification of this information may be grounds for termination from the program and result in prosecution under federal and state laws. • I am responsible for notifying my Case Manager in writing immediately (within 15 days) if there is a change in my family’s income or household members during the year and for updating this information during annual re-certification. • Neither I nor any family member is receiving assistance under any other part of this program or under any other public housing assistance program, including but not limited to, Section 8, HOME, or other publicly assisted housing. • Assistance under this program may not be paid to me or to any family member, even if that family member is my landlord/mortgagee and does not reside with me. • Assistance under this program is contingent on continued grant funding for the program.
E-Signature of Applicant / Head of Household:*
Date:*
MM slash DD slash YYYY
E-Signature of Spouse or Co-Tenant (if applicable):
Date:
MM slash DD slash YYYY
Declaration of Homelessness
Applicant Name:*
First Last
Today's Date:*
MM slash DD slash YYYY
Social Security Number:*
Birth Date:*
MM slash DD slash YYYY
I certify that: My household is “homeless”, as an individual or family who meets one of the following categories. Check Category 1 or Category 1 & 4, and criteria met within that category.*
- Category 1: Literally Homeless
- Residing in a place not meant for human habitation (streets, cars, parks, sidewalks, abandoned buildings
- Residing in homeless shelters or treatment program
- Being discharged within a week from an institution or a jail/prison in which the person has been a resident for 90 days or less and no subsequent residence has been identified and lacks the resources and support networks needed to obtain housing
- Category 4: Fleeing/Attempting to Flee DV (must also check Literally Homeless above)
Acknowledgment*
I certify and acknowledge that the information provided here will be used to determine my eligibility and amount of assistance and that the information is true and correct to the best of my knowledge. This information is subject to verification, and falsification of this information may be grounds for termination from the program and result in prosecution under federal and state laws.
E-Signature of Applicant / Head of Household:*
Date:*
MM slash DD slash YYYY
E-Signature of Spouse or Co-Tenant (if applicable):
Date:
MM slash DD slash YYYY
E-Signature of Case Worker:*
Date:*
MM slash DD slash YYYY
Confidentiality/Release of Information
Effective Date:*
MM slash DD slash YYYY
Expiration Date:*
MM slash DD slash YYYY
Neighbor Name:*
First Last
Date of Birth:*
MM slash DD slash YYYY
Phone:*
Alternate Phone:
Statement of Confidentiality
It is the policy of Family Gateway to treat your records as confidential and not disclose them, without your written authorization, subject to certain disclosures that are permitted or required by law. This means that confidential information will not be disclosed (even to family members) without your authorization. In an effort, though, to provide and/or verify services and resources, including medical information, it is necessary that we have your authorization to release information to and obtain information from other participating agencies/entities/persons involved in providing services to you. This information may be entered in a computer database that other social service agencies are able to access. Program services will be contingent on the program’s ability to share information with these other agencies/entities/persons.
Authorization:*
I understand that confidential information may be shared with the agencies/entities/persons x’d below, and that such agencies/entities/persons may share confidential information with us, for the purpose of providing all Family Gateway services.
_x_ AA/NA Support Groups
_x_ ADAPT
_x_ APAA (Persons Affect/Addiction)
_x_ Apartment Mgmt & Company
_x_ Social Security Administration
_x_ Austin Street Center
_x_ Dallas County
_x_ Dallas Housing Authority
_x_ Dallas Life Foundation
_x_ DARS (Assistive Rehab Services)
_x_ DART (Dallas Area Rapid Transit)
_x_ Family Compass
_x_ H.U.D.
_x_ Homeward Bound
_x_ MDHA (HMIS-IRIS)
_x_ MetroCare Services
_x_ Parkland Hospital/Systems
_x_ Solace
_x_ Texas Dept of Criminal Justice
_x_ Texas Workforce Commission
_x_ The Bridge
_x_ The Salvation Army
_x_ Nexus
_x_ The Stewpot/Crossroads
_x_ Turtle Creek
_x_ TX Dept of Health/Human Svcs
_x_ Union Gospel
_x_ Veteran’s Administration
_x_ City of Dallas
_x_ LIFT (Literacy Instruction for TX)
_x_ Baylor Hospital/Systems
_x_CitySquare’s L.A.W Dept.
_x_ IPS
_x_ Other: CitySquare
_x_ Other:_____________
In the event of an emergency, or in the event that Family Gateway is unable to contact me, I authorize Family Gateway to contact the person(s) below:*
Name/Relation Telephone
Authorization:*
I authorize Family Gateway to share confidential information with the agencies/entities/persons identified above. This form will expire three (3) years from the effective date. I may withdraw this authorization at any time in writing. I further release Family Gateway from all legal responsibility and liability that may arise from the action I have authorized here.
Client's E-Signature:*
Date:*
MM slash DD slash YYYY
E-Signature of Spouse or Co-Tenant (if applicable):
Date:
MM slash DD slash YYYY
Case Manager's E-Signature:*
Date:*
MM slash DD slash YYYY
Income Certification
Please check one:*
- Initial Certification
- Recertification
Subrecipient Name:*
TDHCA Contract #:
Staff Name:
Staff Title:
Subrecipient Address:*
Street Address Address Line 2 City State ZIP Code
Subrecipient Phone:
Subrecipient Email:
Subrecipient Fax:
Part II: Household Composition:*
Last Name First Name & MI Relationship to Head of Household Date of Birth Student Status (FT/PT/NA) Last 4 digits of SSN
Part III: Gross Annual Income (Use Annual Amounts)*
Name Employment or Wages Social Security/Pensions Public Assistance Other Income
Total Employment or Wages ($):*
Total Social Security/Pensions ($):*
Total Public Assistance ($):*
Total Other Income ($):*
Total Income ($) = Employment or Wages + Social Security/Pensions + Public Assistance + Other Income:*
Part IV: Income from Other Assets*
Name Type of Asset C/I Cash Value of Asset Annual Income from Asset
Enter Total Cash Value of Assets if over $5,000:
Enter Imputed Income = Total Cash Value of Assets x 0.06%
Enter the greater amount below: Total Annual Income from Assets or Imputed Income
Total Annual Household Income from All Sources (number above + total income at end of Part III):*
Part V: Household Certification*
The information on this form will be used to determine maximum income eligibility. I/we have provided for each person(s) set forth in Part II acceptable verification of current anticipated annual income. I/we agree to notify the subrecipient and landlord immediately upon any member of the household moving out of the unit or any new member moving in. I/we agree to notify the subrecipient and landlord immediately upon any member becoming a full-time student. Under penalties of perjury, I/we certify that the information presented in this certification is true and accurate to the best of my/our knowledge and belief. The undersigned further understands that providing false representations herein constitutes an act of fraud. False, misleading or incomplete information may result in the termination of the lease agreement.
E-Signature:*
Date:*
MM slash DD slash YYYY
Part VI: Determination of Income Eligibility
Total Annual Gross Income:*
30% of Median Area Income for Household Size:*
Based on the representations herein and upon the proofs and documentation required to be submitted, the representative of the subrecipient has determined that the household income named for the individual(s) in Part II of this Income Certification is:*
- <30% of the Area Median Income
- >=30% of the Area Median Income
E-Signature of Subrecipient Representative:*
Date:*
MM slash DD slash YYYY
Rights
As a Program Participant of City of Dallas you have a right to:  Be treated with respect, dignity and professionalism, and in a caring manner that appreciates differences related to race, ethnicity, national origin, gender, sexual orientation, religion, personal values, age, disability, and economic or veteran status.  Confidentiality. This means that, without your written permission, no information about you is available to anyone outside of Family Gateway, including family members, friends, or outside agencies. However, there are certain exceptions, noted below, with which you should be aware - please read carefully through these exceptions, and be sure to ask your Case Manager if you have any questions: Exceptions to Confidentiality: - If appropriate, your Case Manger may consult with your treating physician or other healthcare providers to coordinate your care; - If you pose a threat of harm to yourself, to another person, or to the A Way Home community, we will take whatever steps are required by law, or permitted by law, to help prevent the potential harm from happening. This may include contacting your family and/or authorities; - In the event of a psychiatric hospitalization; - If you report information indicating that a child, disabled, or elderly person is suffering abuse or neglect; - A court order, issued by a judge, could require us to release information contained in your records, or could require a Family Gateway staff member to testify; - If you have been mandated by Family Gateway staff to seek an evaluation.  Discuss with your Case Manager what information is in your record, and if you sign a release of information authorizing Family Gateway to share information with outside sources, you have a right to discuss specifically what information will be released.  Request a different Case Manager if you become dissatisfied with your initial assignment. Reassignment will depend upon availability of alternate Case Management staff.  Be informed about the services available to you at Family Gateway.  Be provided with a safe environment to conduct your visits in.  Choose to use or not to use other Family Gateway services outside of A Way Home.  Receive accurate and relevant information in a timely manner.  File a grievance if you feel you have been mistreated and/or wronged and expect that the grievance will be investigated appropriately and in confidence.  File an appeal within 10 days of receiving a discharge notice from Family Gateway.
Responsibilities
As a Program Participant of City of Dallas Program you have a responsibility to:  Be respectful of others, including all Family Gateway staff, interns, volunteers, and other program participants.  Be respectful of all property belonging to Family Gateway and to the Owner of Project Site.  Participate in a fit state (not under the influence of drugs or alcohol) in those Family Gateway services you choose.  Participate in visits and other services to maximize your benefits (turn off/silence mobile phones).  Maintain confidentiality regarding information about other program participants in groups or programs conducted by Family Gateway and partnering agencies.  Provide accurate information about yourself, including changes in income, additional household members, and/or marital status, in order to receive quality services.  Keep all scheduled appointments with your Case Manager. If you need to cancel an appointment, please contact your Case Manager 24 hours before the appointment.  Keep apartment unit in a safe and sanitary manner and in compliance with housing habitability standards.  Abide by the terms and conditions set forth by the property owners in the apartment complex lease for the unit in which you reside.  Follow all rules and guidelines listed in your Program Participant Expectations (PPE).
E-Signature of Applicant/Head of Household:*
Date:*
MM slash DD slash YYYY
E-Signature of Spouse or Co-Applicant (if applicable):
Date:
MM slash DD slash YYYY
E-Signature of Case Manager:*
Date:*
MM slash DD slash YYYY

Last Name, First Name, MI	Relationship to You	DOB	Sex	Veteran? Y or N	Race	Highest Grade Completed

Family Member	Wages/Salaries	Benefits/Pensions	Public Assistance	Other Income	Asset Income

Agency	Service	Case Manager	Phone

Name	Amount

CoC Rapid Rehousing Program Application

Metro Dallas Homeless Alliance HMIS Privacy Notice

Applicant Information

Note

Declaration of Homelessness

Confidentiality/Release of Information

Statement of Confidentiality

Income Certification

Part VI: Determination of Income Eligibility

Rights

Responsibilities