Self-Sufficiency Action Planhoh Name: ______

Self-Sufficiency Action PlanHOH Name: ______

Matrix / Customer Responsibilities / Case Manager Responsibilities / Outcome
Income: / Update file as necessary
Employment: / Update file as necessary
Shelter: / Provide Landlord List
Food: / Provided Community Resource List
Childcare: / Refer to JFS Childcare if applicable
Children’s Education: / Refer to Head Start if applicable
Adult Education: / Provide SSCC information if requested
Legal: / Refer to Legal Aid if applicable
Health Care: / Refer to JFS for Medicaid if applicable
Life Skills: / Update as needed
Mental Health: / Refer to SPVMH if applicable
Substance Abuse: / Refer to Fayette Recovery if applicable
Family Relations: / Update file as necessary
Transportation: / Refer to transportation if applicable

HCRP

STAFFCERTIFICATIONOF ELIGIBILITY FORHCRP ASSISTANCE

Purpose:This formserves as documentation that:(1)the programparticipantnamed below meetsall eligibility criteria forHCRPassistance;(2)thiseligibility determination is based on trueand complete information;(3)neither the staff member making thisdetermination norhis or her supervisor arerelated tothe programparticipant throughfamily, business or other personal ties;and (4)thiseligibility determination hasnotresultedfrom, nor will resultin, anyfinancial benefit tothe staff membermakingthisdetermination, his or hersupervisor, or anyone related tothem.

Instructions:This formmustbe completedfor each programparticipantupon thedetermination of his or her eligibility forHCRP assistance.This formmustbe signed and dated by theHCRPstaff person whomakes this determination and thatperson’s supervisor and mustbe kept in the programparticipant’s case file.This form will remain valid,unless a differentstaff person re‐determines theprogramparticipant’s eligibility, in which case a new formwill berequired.

HeadofHouseholdName:
NamesofOtherHouseholdMembers*:

*All members inhousehold thatwill benefit fromHCRPassistanceshould belistedhere.

Requiredcertifications: Each person signingbelowcertifies tothe following:(1)Tothe best of my knowledge, the programparticipantnamed above meets all requirementstoreceive assistance under the HCRP(HCRP).(2)Tothe best of my knowledgeandability, all of the informationused in makingthiseligibility determination is true and complete.(3)Iam notrelated tothe program participantthrough family, business or other personalties.(4)Tothe best ofmy knowledge, neither Inor anyone related tome has received or will receive any financial benefit for thiseligibility determination.(5)I understand thatfraud isinvestigatedby the Departmentof Housingand Urban Development, Officeof InspectorGeneral, and may be punished under Federal laws toinclude, butnotlimitedto, 18U.S.C.1001and 18U.S.C. 641.(6) I understand that if any ofthese certificationsisfound tobe false, Iwill be subjecttocriminal, civiland administrative penalties and sanctions.

HCRP Staff Signature: Date:

HCRP Supervisor Signature: Date:

HCRP Recertification Form

3 Month6 Month9 Month NAME: ______
12 Month15 Month18 Month ______

1. Do you owe any back utility bills? YES NO

If yes, please list the company, account #, and amount below:

(Case Manager attach most recent utilities)

1. Are you current on your rent? YES NO

Case Managerlist the date and time of landlord contact and supporting documentation of arrearages if applicable:

1. Total Monthly Income ______
   

If no 30 day, please provide last 90 days income ______

1. Have you received income from any source in the past 30 or 90 days YES NO
   
2. Has any adult received income from any source in the past 30 or 90 days YES NO

Source / Amount / Recipient(s) / Source / Amount / Recipient(s)
 Alimony or other spousal support / $ / Social Security Income (SSI) / $
Cash assistance/TANF / $ / Social Sec Disability Income (SSDI) / $
Child support / $ / Unemployment / $
Earned Income / $ / VA Service Connected Disability / $
Pension from a former job / $ / Veteran's Pension / $
Retirement from Social Security / $ / Worker’s Compensation / $
Private Disability Insurance / $ / General Assistance / $
Other Sources?
Source______ / $ / Other Sources?
Source______ / $
TOTAL MONTHLY INCOME
(record separately for each adult) / $ / TOTAL MONTHLY INCOME
(record separately for each adult) / $

1. Has any adult received non-cash benefits in the past 30 or 90 days? YES NO

Source / Recipient(s) / Source / Recipient(s)
 / Food Stamps - Amount $ /  / TANF child care services
 / WIC /  / TANF transportation services
 / Section 8, Public Housing, or other ongoing rental assistance /  / Other TANF-funded services
 / Temporary rental assistance /  / Other: ______

1. Is anyone in the household receiving health insurance benefits? YES NO

Source / Recipient(s) / Source / Recipient(s)
 Medicaid / Employer-provided Health Insurance
Medicare / Health insurance obtained through COBRA
State Children’s Health Insurance Program (SCHIP) / Private Pay Health Insurance
Veteran’s Administration (VA) Medical Services / State Health Insurance for Adults
Other / Indian Health Services Program

1. Is anyone in the household pregnant? YES NO

Due date: ______

1. Any criminal history since program enrollment? YES NO
2. Assets

Please list all stocks, bonds, trusts, pensions, or other assets and their value owned by any household member.

1. Have you filed a tax return for this year? YES NO

1. Case Manager explain how client will be homeless “but for” this assistance:

HCRP Subsidy/Budget Planning Worksheet

HEAD OF HOUSEHOLD NAME: ______DATE:______
MONTHLY EXPENSES FOR ______(MONTH)

Cost / Estimate / Actual
Rent
Utilities: Electric
Gas
Water
Telephone
Cell phone
Cable T.V.
Food expenses covered by SNAP income
Food expenses that exceed SNAP income
Baby Formula and or Diapers
Transportation: (car payment, gasoline or bus fare)
Child Care
Medical ( prescriptions, co-pays, medicine needs)
Insurance ( Automobile, Renters/Home Owners)
Household Supplies
Clothing
Personal Needs ( haircut, dry cleaning, etc)
Cigarettes
School Expenses ( tuition, books, lunches, etc)
Recreation/ Community Activities
Installment loans & other debt payments
Storage Unit
Child Support Payments
Furniture
Savings (please specify)
Other (please specify)
A: TOTAL MONTHLY COSTS
Exclude Food covered by SNAP income
B:TOTAL NETMONTLY INCOME
Include: Wages, child support, SSI, OWF (all income) do NOT include SNAP benefit.
Total Costs –Total Income =Total monthly ☐deficit or ☐surplus (check one)
Subsidy Request: Monthly subsidy must equal the total monthly deficit or zero
Please use the space below to describe any costs that need explanation and any steps the client will be taking to decrease their need for subsidy.

Participant Signature ______Date:______

Case Manager Signature ______Date: ______

Third Party Verification of Income

HCRP Applicant Name: ______

Instructions for Employer/Payment Source Representative: This is to certify the income received by the above named individual for purposes of participating in the HCRP program. This information will be used only to determine the eligibility status and level of benefit of the household. 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
HCRP Applicant Release: I hereby authorize the release of the following employment information.
HCRP Applicant 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 and/or Benefit Income (complete one form for each distinct source of income for person named above)

CIRCLE ONE:Social Security/SSIPension/Retirement TANFPublic AssistanceUnemployment Compensation Workers Compensation Alimony Payments Foster Care Payments Child Support Payments
Armed Forces IncomeOther (pls. specify): ______

HCRP Applicant Release: I hereby authorize the release of the following payment and/or benefit information.

HCRP Applicant Signature: ______Date: ______
Payment source representative 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 Signature: ______Date:______
Name, Title: ______
Address and Phone: ______

Self-Declaration of Income

HCRP Applicant Name: ______

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 only that section

I certify, under penalty of perjury, that I currently receive the following income:

Source: ______Amount: ______Frequency: ______
Source: ______Amount: ______Frequency: ______
Source: ______Amount: ______Frequency: ______

HCRP Applicant Signature: ______Date: ______

I certify, under penalty of perjury, that I do not have any income from any source at this time.

HCRP Applicant Signature: ______Date: ______HCRP Staff Verification
I understand that third-party verification is the preferred method of certifying income for HCRP assistance. I understand self-declaration is only permitted when I have attempted to but cannot obtain third party verification.
Documentation of attempt made for third-party verification:
______

HCRP Staff Signature: ______Date: ______

HCRPRecertification Denial

Date: ______

Name: ______

Address: ______

City, State Zip: ______

RE:Housing Stability Program (HCRP) Application Determination

Dear: ______

The HCRP application for you has been denied. HCRP funds are utilized by those households that are homeless or at risk for homelessness that need assistance with a rental security deposit, utility deposit, rental payment, utility payment, moving expense, and/or hotel/motel voucher; have income below 30% of the Area Median Income (AMI); have low-to moderate-barriers to housing; and meet other program criteria.

This letter is in regard to the recent application submitted to the ______Housing Program. You are not eligible to receive HCRP assistance at this time. This decision is based on the following information:

Applicant does not meet eligibility requirements:

Income at or above 30% of the Area Median Income

Housing barriers were not met or exceeded the scope of this program

Other: ______

Application was not completed:

Requested documentation to complete application process was never received

If you would like to be reconsidered, please provide the following items: ______

______

Other: ______

Other: ______

Should you have any questions or concerns, please call ______at (___) ____-_____.

Respectfully,

Staff name

cc: agency file

TAB 5 –RECERTIFICATION

Tab 5 / Date Completed / Initials of Staff Person Completing/Notes
Self Sufficiency Action Plan
Updated Staff Certification Form
HCRP Recertification Form
Budget/Subsidy Planning Worksheet
Verification of Income (Each Adult)
Paystubs, Social Security Statement, Print Outs, etc (12 weeks)
Checking/Savings/IRA/Tax Documents/etc. Print Outs
Self-Declaration of Income (Each Adult)
HCRP Recertification Denial (if applicable)
Copies of updated utilities and PIPP