SHELTER PLUS CARE REFERRAL
Submission Cover Sheet
Submit To: Stephanie Kan, SPC Coordinator
Email: Stephanie.Kan@mbhp.org
Phone: 617-425-6680
Fax: 617-532-7614
From: Sarah Quinn
Email: squinn@aac.org
Phone: 617-450-1013
Fax: 617-437-1186
REFERRAL NAME (New Client):
Program:
DND
DHCD
Projecto Opciones
Project Type:
Sponsor
HOPWA
YHI
Tenant
Grant Number:
Former Tenant Leaving This Allocation Slot:
SPC Referral – Effective 1/1/2014
Project
SHELTER PLUS CARE REFERRAL FORM
To be completed by the Service Provider in collaboration with Individuals and ALL members of a Family that is receiving
services (including children).
Send To MBHP:
Stephanie Kan, Program Coordinator
Phone: 617-425-6680
Fax: 617-532-7614
Email: Stephanie.Kan@mbhp.org
Referring Agency:
Name of Referring Coordinator: Sarah Quinn
Email: squinn@aac.org
Phone: 617-450-1013
Fax: 617-437-1186
Client Name:
Submission Date:
Program Type: DND
DHCD
HOPWA
LHI
Grant Number:
Project Type: Sponsor
| Tenant
| Project
Program Name (If Applicable):
Prospective Street Address:
YHI
Our selection process for programmatic and housing eligibility certifies that the following client meets the
definition of “homeless” and a “person with disabilities” as indicated in the HUD Regulations.
Qualifying Homelessness Status:
A homeless person lacks a fixed, regular, and adequate night time residence and primarily resides in (Choose One):
Places not meant for human habitation, such as cars, parks, sidewalks, and abandoned buildings.
Emergency Shelters or Welfare Motels
Transitional or Supportive Housing for homeless persons who originally came from streets or emergency shelters.
Either:
Traditional Transitional or Supportive Housing program for Any Period of time as long as client was
officially homeless (either streets or shelter) Immediately Prior to entering transitional housing
Hospital or other non-penal institution for 90 consecutive days or less as long as client was officially
homeless (either streets or shelter) Immediately Prior to entering institution
Transitional Program Name:
Length of Stay:
Previous Dwelling:
Please also include Verification of Homelessness on Referring Agency letterhead (see below list for details)
Qualifying Disability Status:
A person with disabilities has a disability that is expected to be of long-continued and indefinite duration; substantially
impedes his or her ability to live independently; and is of such nature that the disability could be improved by more
suitable housing conditions. Indicate primary, targeted disability of applicant:
Serious Mental Illness
Chronic Alcohol and/or other Drug Abuse
Dual Diagnosis (Serious Mental Illness and/or Chronic Alcohol/Drug Abuse)
HIV/AIDS and related Diseases
Other Diseases
In my professional judgment, said client has been stabilized, is not actively abusing substances, and has demonstrated a
commitment to an individual treatment plan. At this time, the applicant named below is ready to occupy rental housing
with supportive services in the community.
Service Provider Signature:
Date:
A HUD Disability Verification Form must also be submitted (see below list for details)
SPC Referral – Effective 1/1/2014
Please include these Required Documents:
1. Referral Form
a. Completely Filled In and Signed
2. Referral Application
a. Write in “Zero,” “None,” “N/A,” or “0” for Both Income and Assets if applicable – Do NOT leave blank
3. HUD Client Intake & Assessment Form
a. One for EACH Family Member including children
4. HUD Verification of Disability Form
a. Must be completed by a fully licensed medical professional who is appropriate for determining the
disabling effects of their condition (ex. a mental health doctor, nurse, or therapist, or PCP for mental
health condition)
b. Must be Fully Completed in Both sections, including signatures and license #
c. Or a Letter from Medical Practitioner on Letterhead confirming disability as described in disability form
and with signature and license #
d. Or a SSI or SSDI approval or payment letter (Not SS)
e. A diagnosis of HIV/AIDS is sufficient. For All other conditions, must be shown to be actively disabling.
5. Verification of Homelessness on Referring Agency Letterhead
a. Use Enclosed Form Only if Street Homeless
b. If currently in Transitional/Supportive Housing, Hospital, or other non-penal institution, either:
i. Current facility must provide letter and must also confirm date and shelter where client resided
immediately prior to entry
ii. Or current facility AND prior shelter each provide a separate letter
6. Fair Information Practices Act
a. One for EACH Adult
7. Privacy Act Notice, Authorization for Financial Release, CORI Release
a. Must sign and complete All 3 sections
b. One for EACH Adult
8. Proof of All Forms of Income within 60 days for Each Family Member:
a. If No Income, write in “Zero,” “None,” “N/A,” or “0” on Referral Application – Do NOT leave blank
b. Earned Income (Wages or Unemployment)
i. At least 5 consecutive and most recent weeks of paystubs
ii. Or a letter from employer (signed, dated, and on letterhead) confirming position, and Gross
wages + frequency (ex. “__client name___ is a __position__ at __company name__ and is paid
__Gross wages $/wk___”)
iii. Unemployment Letter indicating amount being paid
c. Child Support
i. If formal DOR ordered child support, provide a Letter or Printout from Child Support Enforcement
verifying that you do or do not receive Child Support. You may call 1-800-322-2733 to request an
updated copy. This is often also listed on DTA benefit letters.
ii. If informal voluntary child support, a signed and dated letter from payer outlining amount +
frequency, and for which child (ex. “I, __payee name___, pay __client name__ __$/wk__ in
support of my child, ___child name__”)
d. TAFDC, EAEDC, SNAP, etc.
i. Letter or printout from your area’s Department of Transitional Assistance (DTA) Office
ii. You may call 1-800-632-8095 to obtain this information
e. Social Security (SS, SSI, SSDI)
i. Printout or letter verifying Social Security, SSI, or SSDI Benefits
ii. You may call 1-800-772-1213 to obtain this information
SPC Referral – Effective 1/1/2014
9. Verification of Assets
a. If No Assets, write in “Zero,” “None,” “N/A,” or “0” on Referral Application – Do NOT leave blank
b. Bank statement or investment statement within the last 60 days
10. Verification of Medical Expenses for up to 1yr (if applicable and requesting deduction)
a. Must indicate the qualifying expense item
b. Must clearly show that client actually paid this amount (not just a bill showing due)
11. Verification of Child Care Expenses for up to 1yr (if applicable and requesting deduction)
a. Must indicate the qualifying expense item
b. Must clearly show that client actually paid this amount (not just a bill showing due)
12. Social Security Card for Each Family Member
a. Or a printout from Social Security clearly indicating assigned social security number
b. Or notification that member does not have a social security number
13. Photo ID for Each Adult
14. Birth Certificate of Each Family Member
a. Either certificate or letter from either city registry or hospital
b. Or clearly indicate if birth certificate is not available and provide a passport, green card, permanent
resident card, immigration documentation, or military discharge (DD 214) papers clearly indicating
birthdate
SPC Referral – Effective 1/1/2014
RENTAL ASSISTANCE APPLICATION
Name:
Telephone:
Current Address:
Service Provider: AIDS Action Committee
Case Manager:
Telephone & Email:
I. FAMILY COMPOSITION: (attach extra page if necessary)
Name: Last, First
Date of Birth
Relationship
to Head of
Household
Sex
HEAD
M
M
M
M
M
M
M
M
F
F
F
F
F
F
F
F
Ethnicity
Race
H
H
H
H
H
H
H
H
1234
1234
1234
1234
1234
1234
1234
1234
NH
NH
NH
NH
NH
NH
NH
NH
SSN
SEX CATEGORIES: M – Male, F – Female
ETHNICITY CATEGORIES: H – Hispanic, NH – Non-Hispanic
RACE CATEGORIES: 1 – White 2- Black 3- Native American 4-Asian/ Pacific Islander
Are you expecting a change in your household composition?
If yes, explain:
Yes No
II. INCOME: Please list all money expected to be earned or received in the next 12 months by each household member who is 18
years of age or older (this includes full time students). This list should include all types of income received by household members,
such as TAFDC or public assistance, salaries or wages, disability compensation, social security benefits and/ or SSI, child support
payments or alimony. Please attach proof of income for each source. **Be sure to write N/A, None, or Zero as appropriate**
Person Receiving Income
Source or Type of Income
(TAFDC, SSI, salary, etc.)
Name & Address of Employer
or Source of Income
Gross Amount of
Income (specify
weekly/ monthly, etc.)
Annual Gross Income $
ADDITIONAL BENEFITS/SOURCES OF INCOME:
1. Please indicate whether any household members are receiving the following assistance. Circle “yes” or “no”. If
“yes,” state the number of people receiving the assistance.
MASS HEALTH
MEDICARE
FOOD STAMPS
2.
Yes
Yes
Yes
No
No
No
Are you a veteran or a recipient of veteran’s benefits?
Yes
SPC Referral – Effective 1/1/2014
No
III. ASSETS: List all assets owned, controlled, or disposed of with past 2 years (checking, savings, IRA, stocks, bonds, property, etc) **Be sure to
write N/A, None, or Zero as appropriate**
Household Member
Description and Account # (Checking, Savings, CD)
Have you sold or transferred any property in the last two years? (circle one)
Yes
Value /Balance
No
IV. ADDITIONAL QUESTIONS
1. Do you pay for childcare (for children under 13) which enables you or another family member to go to work or go to
school? (circle one)
Yes
No
If Yes, what is the amount you expect to spend on this childcare in the next 12 months? $ _______
2. Elderly or disabled household ONLY: Do you have any medical expenses that are not covered by insurance? Do you
pay for a care attendant or any equipment for the handicapped member(s) of the family necessary to permit that person
or someone else in the family to work?
Yes
No
If yes, what is the amount you expect to spend on these items in the next 12 months? Please attach
invoices/receipts for consideration.
$________
3. Have you or any member of your household ever participated in the manufacture, sale, or distribution of illegal drugs?
Yes
No
If yes, when did this occur? __________
4. Have you or any member of your household ever participated in a violent criminal activity? (this includes murder,
manslaughter, assault and battery, rape, robbery, burglary and arson)
Yes
No
Answering “yes” to one of the previous questions does not mean you will automatically be denied HOPWA assistance. Each case will be de reviewed
to determine if there are mitigating circumstances.
Submitting a false response is grounds for denial or termination of HOPWA assistance.
Be advised that MBHP does conduct a criminal records check for all adult household members before providing rental assistance.
SPC Referral – Effective 1/1/2014
HUD Client Intake and Assessment Form
**Please submit a copy of this form for EVERY Family Member Including Children**
To be completed by Service Provider with Client Family
PARTICIPANT INFORMATION:
First Name:
Last Name:
Service Provider: AIDS Action Committee
Date Completed:
Date of Birth:
Social Security Number:
Gender (Check One):
Ethnicity (Check One):
Male
Female
Hispanic/Latino
Latino
Transgendered Male to Female
Transgendered Female to Male
Other
Refused
Non-Hispanic/Non-
Don’t Know
Refused
Don’t Know
Primary Race (Check One):
American Indian or Alaskan Native
Asian
Black or African-American
White
Native Hawaiian/Pacific Islander
Don’t Know
Refused
Secondary Race (Check If Applicable):
American Indian or Alaskan Native
Asian
Black or African-American
White
Native Hawaiian/Pacific Islander
Don’t Know
Refused
This Client is a (Check One):
Single Adult
Head of Household
A child receiving services as part of a family
An Adult receiving services as part of a family; not the Head of Household
Name of the Head of Household ____
SPC Referral – Effective 1/1/2014
___________________
An Unaccompanied Youth
To be completed by the Service Provider in collaboration with Individuals and all members of a Family that is receiving services (including
children).
HISTORY OF HOUSING AND HOMELESSNESS
Housing Status: (see definitions)
Literally Homeless
housing
Stably Housed
Housed & at imminent risk of losing housing
Don’t Know
Housed & at risk of losing
Refused
Is the Client/Family Chronically Homeless? :
Yes
No
A client is chronically homeless if s/he is an unaccompanied adult or a family with at least one adult member who has a disabling condition who
has been continuously homeless (sleeping in a place not meant for human habitation (e.g. living on the streets) and/or in an emergency homeless
shelter for at least a year or episodically homeless at least 4 times in the last 3 years.
Please indicate the type of housing you stayed in last night:
Place not meant for habitation (street, car, etc.)
Emergency Shelter, including hotel/motel with voucher
Transitional Housing for the Homeless
Permanent Housing for Formerly Homeless (SHP, S+C, Mod Rehab)
Psychiatric Hospital or Facility
Hospital (Non-Psychiatric)
Substance Abuse Treatment Facility
Rental by Client with No Subsidy
Ownership by Client with No Subsidy
Staying/Living with Family
Staying/Living with Friends
Hotel/Motel Without Voucher
Foster Care/Foster Care Group Home
Safe Haven
Rental by Client with VASH
Rental by Client with Non-VASH Subsidy
Ownership by Client with Subsidy
Jail/Prison/Juvenile facility
Other:
Don’t Know
Refused
How long have you stayed there?
One week or less More than one week but less than
one month
One to three months
More than three months but less than one year
One year or longer
Don’t Know
Refused
Zip Code of Last Permanent Address:
SPC Referral – Effective 1/1/2014
Are you a victim/survivor of domestic
violence?
Yes
No
Don’t
Know
Refused
If yes, how recent was the domestic violence
situation?
Within Three Months
Three-Six Months Ago
More Than a Year Ago
Client Refused to Report
To be completed by the Service Provider in collaboration with Individuals and all members of a Family that is receiving services (including
children).
VETERAN INFORMATION
Has the client served on Active Duty in the Armed
Forces of the United States?
Post September 11, 2001 (9/11/01 - Present)
Yes
No
Don’t Know
Refused
If No, skip to Disability Information
If Yes, Please Continue
Duration of Duty (in months):
Did the Client Serve in a War Zone?
Yes
No
Persian Gulf (August, 1991 - September 10, 2001)
Post Vietnam (May 1975 - July 1991)
Vietnam Era (August 1964 - April 1975)
Between Korea and Vietnam (February 1955 - July
1964)
Korean War (June 1950 – January 1955)
Between WWII and Korean War (August 1947 – May
1950)
World War II (September 1940 – July 1947)
Client Doesn’t Know
Client Refused to Report
How Many Months Did the Client Serve in a
War Zone?
If Client Served in a War Zone, Did They
Receive Hostile or Friendly Fire?
Client Doesn’t Know
Client Refused to Report
If Yes, Which War Zone?
Europe
North America
Laos/Cambodia
South Pacific
South China Sea
Other:
Refused to Report
Military Service Era (Check all that Apply):
China/Burma/India
Vietnam
Korea
Persian Gulf
Afghanistan
Doesn’t Know
Branches of the Military Client Served (Check All
that Apply):
Army
Air Force
Navy
Marines
Other:
SPC Referral – Effective 1/1/2014
Yes
No
Client Doesn’t Know
Client Refused to Report
What is the Client’s Military Discharge Status?
Honroable
General
Medical
Bad Conduct
Dishonorable
Other:
Doesn’t Know
Refused to Report
To be completed by the Service Provider in collaboration with Individuals and all members of a Family that is receiving services (including
children).
DISABILITY INFORMATION
Does the Client Have a Physical Disability?
Yes
No
Doesn’t Know
Refused to Report
Does the Client Have a Developmental Disability?
Yes
No
Doesn’t Know
Refused to Report
If Yes, Is the Client Currently Receiving Treatment?
Yes
No
Doesn’t Know
Refused to Report
If Yes, Is the Client Currently Receiving Treatment?
Yes
No
Doesn’t Know
Refused to Report
Does the Client Have HIV/AIDS?
Yes
No
Doesn’t Know
Refused to Report
Does the Client Have a Mental Health Condition?
Yes
No
Don’t Know
Refused to Report
If Yes, Is the Client Currently Receiving Treatment?
Yes
No
Doesn’t Know
Refused to Report
If Yes, Is the Mental Health Condition of Long
Duration:
Yes
No
Doesn’t Know
Refused to Report
If Yes, Is the Client Currently Receiving Treatment?
Yes
No
Doesn’t Know
Refused to Report
Does the Client Have a Substance Abuse Problem?
No
Alchol Abuse
Drug Abuse
Does the Client Have a Chronic Health Condition
(Heat/Lung Disease, Diabetes, Arthritis, Brain
Injury, Dementia, Cancer, Stroke, etc.)?
Yes
No
Doesn’t Know
Refused to Report
If Yes, Is the Substance Abuse Problem Expected to
be of Long Duration and Substantially Impair The
Client’s Ability to Live Independently:
Yes
No
If yes, is the Client Receiving Treatment/Services for
this Condition?
Yes
No
Doesn’t Know
Refused to Report
If Yes, Is the Client Currently Receiving Treatment?
Yes
No
Doesn’t Know
Refused to Report
Does the Client Have a Disabling Condition?
Yes
No
Doesn’t Know
Refused to Report
Is the Client Pregnant?
Yes
No
Doesn’t Know
Refused to Report
Compared to other people their age, how would you
rate the client’s health?
Both Drugs and Alcohol
Client Doesn’t Know
Client Refused to Report
If Yes, What is the Due Date?
SPC Referral – Effective 1/1/2014
Excellent
Very Good
Good
Fair
Poor
To be completed by the Service Provider in collaboration with Individuals and all members of a Family that is receiving services (including
children).
EMPLOYMENT INFORMATION
(All Clients 18 and Older)
Is the Client Currently Employed
Yes
Doesn’t Know
If Unemployed, Is The Client Looking for Work? If
Employed, is the Client Looking for Additional
Employment or Increased Hours?
No
Refused to Report
If Yes, How Many Hours Did the Client Work in the
Last Week?
Yes
Doesn’t Know
No
Refused to Report
Tenure of Employment:
Permanent
Temporary
Seasonal
Client Doesn’t Know
Client Refused to Report
EDUCATION INFORMATION
(All Clients 18 and Older)
Is the Client in School or Working toward a Degree
or Certificate?
Yes
Doesn’t Know
No
Refused to Report
What is the Highest Level of School the Client Has
Completed?
None
Nursery School to 4th Grade
5th or 6th Grade
7th to 8th Grade
9th Grade
10th Grade
11th Grade
12th Grade, No Diploma
High School Diploma
GED
Post-Secondary School
Client Doesn’t Know
Client Refused to Report
SPC Referral – Effective 1/1/2014
Has the Client Ever Received Vocational Training or
an Apprenticeship Certificate?
Yes
Doesn’t Know
No
Refused to Report
If the Client Has Enrolled in Post-Secondary
Education, What Degree(s) Has the Client Earned?
None
Associate’s Degree
Bachelor’s Degree
Masters
Doctorate
Other Graduate/Professional Degree (List)
Certificate of Advanced Training or Skilled Artisan
Client Doesn’t Know
Client Refused to Report
CHILDREN UNDER 18
Is the Child Enrolled in School?
Yes
Doesn’t Know
No
Refused to Report
If Yes:
Name of School:
School Type:
Public
Parochial or Private School
Client Doesn’t Know
Client Refused to Report
Was/Is Child Connected to McKinney-Vento
Homelessness Assistance Act School Liaison?
Yes
Doesn’t Know
No
Refused to Report
SPC Referral – Effective 1/1/2014
If Child is not Enrolled:
Last Date of Enrollment:
Problems Enrolling:
None
Residency Requirements
Availability of School Records
Birth Certificates
Legal Guardianship Requirements
Transportation
Lack of Available Preschool
Immunization Requirements
Physical Examination Records
Child Not School Age
Other:
Client Doesn’t Know
Client Refused to Report
INCOME INFORMATION
Have you received any income in the past 30 days?
Yes
No
Don’t Know
If yes, Check the Boxes and Indicate Amount Receivied: Earned Income:
Refused
Unemployment Insurance:
Veteran’s Disability:
Supplemental Security Insurance (SSI):
Social Security Disability Income (SSDI):
Private Disability Insurance:
Worker’s Compensation:
Temporary Assistance for Needy Families (TANF):
General Assistance (GA):
Retirement Income from Social Security:
Veteran’s Pension:
Pension:
Alimony of Spousal Support:
Child Support:
Other:
Have you received any non-cash benefits in the past 30 days? (SNAP, Health coverage, Public Housing)
Yes
No
Don’t Know
Refused
Please check the box next to each benefit you receive:
Supplemental Nutrition Assistance Program (SNAP, Formerly Food Stamps) Amount
Special Supplemental Nutrition Program for Women, Infants & Children (WIC)
LIHEAP/Fuel Assistance
Veteran’s Administration (VA) Medical Services
TANF Child Care Services
TANF Transportation
Other TANF Funded services
Section 8, Public Housing, or other Rental Assistance
MEDICAID
MEDICARE
State Children’s Health Insurance Program (SCHIP)
Commonwealth Care
Children’s Medical Security Plan
Commonwealth Choice
Health Safety Net
Medical Security Plan (for persons receiving Unemployment Comp)
Other Source ___________________
Do you have Private Medical Insurance? (COBRA, insured by employer)
Yes
No
Don’t Know
Refused
Name of Private Medical Insurance:
SPC Referral – Effective 1/1/2014
Shelter Plus Care Disability Verification Form
I hereby grant permission to Metropolitan Boston Housing Partnership to obtain all medical information it deems necessary in
determining my eligibility for the Shelter Plus Care Program. This release shall remain effective for one year from the date appearing
below.
__
____
________________________________________
(Date)
(Signature)
____
____________
(Social Security Number)
TO:
RE:
SS#:
This agency is responsible for determining the eligibility of applicants who seek to participate in the Shelter Plus Care Program. U.S.
Department of Housing and Urban Development (HUD) regulations establish criteria which must be met for an applicant to be
determined (based on disabled or handicapped status) eligible.
Has a disability, as defined in Section 223 of the Social Security Act [42 USC 423] defines disability as:
 “Inability to engage in any substantial, gainful activity by reason of any medically determinable physical or
mental impairment which can be expected to result in death or which has lasted or can be expected to last for a
continuous period of not less than 12 months,” or
 “In the case of an individual who attained the age of 55 and is blind and unable by reason of such blindness to
engage in substantial, gainful activity requiring skills or ability comparable to those of any gainful activity in
which he has previously engaged with some regularity and over a substantial period of time.”
Is determined, pursuant to HUD regulations, to have a physical, mental, or emotional impairment that:
 Is expected to be of long-continued and indefinite duration;
 Substantially impedes his or her ability to live independently, and
 Is of such a nature that the ability to live independently could be improved by more suitable housing conditions; or
Has a developmental disability as defined in 42 U.S.C. 6001. Section 102(7) of the Developmental Disabilities Assistance and
Bill of Rights Act [42 U.S.C. 6001(7)] defines developmental disability in functional terms as:
“Severe chronic disability that:
 Is attributable to a mental or physical impairment or combination of mental and physical impairments;
 Is manifested before the person attains age 22;
 Is likely to continue indefinitely;
 Results in substantial functional limitation in three or more of the following areas of major life activity: (1) self-care, (2)
receptive and responsive language, (3) learning, (4) mobility, (5) self-direction, (6) capacity for independent living, and
(7) economic self-sufficiency; and
 Reflects the person’s need for a combination and sequence of special, interdisciplinary, or generic care, treatment, or
other services which are of lifelong or extended duration and are individually planned and coordinated.”
Other:
HUD’s definition does not exclude persons who have the disease of acquired immunodeficiency syndrome or any conditions arising
from the etiologic agent for acquired immunodeficiency syndromes.
I certify that to the best of my knowledge and belief the above information is correct.
_________________________________________________
(Signature and Title)
_________________________________________________
(Name and Title – Printed)
_________________________________________________
(Organization and Address)
_________________________________________________
(Phone or Email)
SPC Referral – Effective 1/1/2014
___________________
(License Number)
______________
(Date)
Verification of Homelessness
To be eligible for participation in the McKinney-Vento Supportive Housing Program (SHP) Permanent Housing Programs and/or Shelter Plus Care (SPC) Programs, an
applicant must be experiencing homeless as defined by HUD. A person is considered homeless only when he/she resides in one of the following places: (1) In places
not meant for human habitation, such as cars, parks, sidewalks, abandoned buildings (on the street); (2) In an emergency shelter; (3) In transitional or supportive
housing for homeless persons who originally came from the streets or emergency shelters; (4) In any of the above places but is spending a short time (up to 30
consecutive days) in a hospital or other institution.
I hereby verify that the referred individual __________
___________ is currently homeless and is:
Sleeping in places not meant for human habitation (e.g. cars, parks, sidewalks, abandon buildings).
Location:
Sleeping in an emergency shelter or a residence that is part of an established shelter system. The client has been staying at
and entered the shelter system on
.
Graduating from a transitional housing program with a stay of no longer than 24 months and was homeless
(as defined above) immediately prior to entering transitional housing:
name of transitional housing program
Date entered program:
Homelessness circumstances immediately prior to transitional stay:
Being discharged from a jail or institution with a length of stay of less than 30 days and was homeless
(as defined above) immediately prior to inpatient stay
Date entered hospital/institution:
Homelessness circumstances prior to inpatient stay:
The above-named individual should be counted as chronically homeless because s/he is an unaccompanied Individual and:
S/he has a disabling condition, defined as: “a diagnosable substance abuse disorder, serious mental illness,
developmental disability, or chronic physical illness or disability including the co-occurrence of two or more
of these conditions. A disabling condition limits an individual’s ability to work or perform one or more
activities of daily living (ADL)
S/he has been continuously homeless (sleeping in a place not meant for human habitation (e.g. living on the
streets) and/or in an emergency homeless shelter for at least a year or episodically homeless at least 4 times
in the last 3 years Staff must attach a statement signed & dated by staff or the client, giving the dates & locations
(street or shelters) where the client lived during the period given as the basis for designating him/her chronically
homeless.
Note: A client who has been determined to have been chronically homeless prior to entering a HUD-funded program
should be counted as chronically homeless while they are in that or subsequent HUD-funded programs.
A statement signed by staff or the client about such prior homelessness is attached or appears on reverse side of
this form
I understand that false statements or information are punishable under federal law.
___________________________________________________________
Signature of Authorized Program Staff
_________________________________________________
Name and Title – Printed
_________________________________________________
Organization and Address
_________________________________________
Phone or Email
SPC Referral – Effective 1/1/2014
_______________
Date
FAIR INFORMATION PRACTICES ACT
STATEMENT OF RIGHTS
Metropolitan Boston Housing Partnership, Inc. (MBHP) collects information about applicants and tenants to determine
eligibility, amount of rent, and correct apartment size. The information collected is used to manage the housing programs,
to protect the public’s financial interest, and to verify the accuracy of information submitted. When permitted by law, it
may be released to government agencies, local public housing authorities, other regional non-profit housing agencies, and
to civil or criminal investigators and prosecutors. Otherwise, the information will be kept confidential and used by MBHP
staff in the course of their duties.
The Fair Information practices Act established requirements governing MBHP’s use and disclosure of the information it
collects. Applications and tenants may give or withhold their permission when requested by MBHP to provide
information. However, failure to permit MBHP to obtain the required information may result in delay, ineligibility for
programs, or termination of tenancy or housing subsidy. The provision of false or incomplete information is a criminal
offense punishable by fines and/or imprisonment.
As an applicant or tenant, you have the following rights in regard to the information collected about you:
1. No information may be used for any purpose other than those described above without your consent.
2. No information may be voluntarily disclosed to any person other than those described above without your
consent. If we receive a legal order to release the information, we will notify you.
3. You or your authorized representative have a right to inspect and copy any information collected about you.
4. You may ask questions and receive answers from MBHP as to how we collect and use your information.
5. You may object to the collection, maintenance, dissemination, use, accuracy, completeness or type of information
we hold about you. If you object, we will investigate your objection and will either correct the problem or make
your objection a part of the file. If you are dissatisfied, you may appeal to the Executive Offices of the
Department of Housing and Community Development (DHCD) or the Department of Neighborhood
Development (DND) depending on which grantee funds your program.
I have read and understood this Fair Information Practices Statement of Rights and have received a copy for future
reference.
________________________
____________________________________
DATE
SIGNATURE
_____
_______________________________
APPLICANT’S NAME (PRINTED)
SPC Referral – Effective 1/1/2014
SHELTER PLUS CARE AUTHORIZATION FORM
Applicant’s Name (Printed): ___
_______________________________________
APPLICANT’S CERTIFICATION
I am certifying that I meet the eligibility criteria for MBHP’s HOPWA Program. I understand that this
application is not an offer of housing assistance. If I am offered a rental subsidy and I am not able to locate a
unit within the time allowed, I will have to re-apply to get further assistance. I understand that it is my
responsibility to inform the housing agency in writing of an change in my address, income, or household
composition. I authorize the housing agency to verify the truth of the information I have given in this
application. I understand that the information contained in my application may be subject to audit. I
understand that any false statement or misrepresentation contained in my application may be subject to audit.
I understand that any false statement or misrepresentation may result in the cancellation of my application
and program participation once I begin to receive rental assistance.
I CERTIFY THAT THE INFORMATION I HAVE GIVEN IN THIS APPLICATION IS TRUE AND
CORRECT. THIS APPLICATION IS SIGNED UNDER PAIN AND PENALTY OF PERJURY.
___________________________________________
________________________________
Applicant’s Signature
Date
AUTHORIZATION FOR RELEASE OF INFORMATION
I, __
________________________________, hereby authorize Metropolitan Boston Housing Partnership,
Inc., and its staff to contact any federal, state or local agencies or authorities, or any private businesses,
corporations, financial institutions or persons it deems necessary to obtain any information or materials
needed to complete my application for participation in any housing assistance program administered by
Metropolitan Boston Housing Partnership, Inc., or to ensure compliance with program requirements should I
become a participant.
___
_____________
Applicant’s Social Security #
_______________________________
________________________
Applicant’s Signature
Date
DRUG AND/OR VIOLENT CRIMINAL ACTIVITY NOTIFICATION
I, __
__________________________________, acknowledge that Metropolitan Boston Housing
Partnership, Inc. (MBHP) has the right to obtain information from law enforcement agencies (e.g., local police
departments, Criminal History Systems Board) regarding myself and all adult members of my family relating
to any drug related or violent criminal activity.
I acknowledge that if MBHP determines that I or any adult family member has participated in such drug
related or violent criminal activity, then I and my family may be denied eligibility or may be terminated from
the HOPWA Rental Assistance Program.
_________________
______________________________
Date
SPC Referral – Effective 1/1/2014
Applicant’s Signature