Exhibit C – Page 1
CITY OF ANAHEIM
HOMELESS ASSISTANCE PROGRAM FOR FAMILIES (HAP-F)
TENANT-BASED RENTAL ASSISTANCE PROGRAM (TBRA)
OPERATING GUIDELINES
PROGRAM OVERVIEW
In 2013, the City of Anaheim (City) established the Homelessness Assistance Pilot Program (HAPP) with the objective of assisting homeless families with children transition into permanent supportive housing by providing a combination of supportive services and rental assistance.
The pilot program provided a combination of supportive services and housing assistance. The supportive service component is funded with Emergency Solutions Grant (ESG) funds and the housing component is funded with HOME funds. The housing component of the HAPP program is a Tenant-Based Rental Assistance (TBRA) p rogram and follows all the requirements of the HOME Program, as set forth in the HOME program under Section 24, Part 92, of the Code of Federal Regulations (24 CFR 92).
To facilitate the delivery of HAPP services, the City published a Request for Proposals (RFP) and selected the Illumination Foundation to administer the program. Through HAPP, the partnership was successful in housing over 160 families in an 8 year period. Additionally, the program provided significant data which has been used to modify and enhance the Homeless System of Care in Anaheim.
Based on the success of HAP P, the City approved the removal of the pilot status of the program and continuation of ESG and HOME funds for the Homeless Assistance Program for Families (HAP -F). Key indicators of success will include the ability to transition off the HAP -F program and remain housed without assistance for at least six months, increases in earned income, sustainable rent burden (at or below 50% of family income), and improvements in school performance including but not limited to increases in school attendance.
The procedures set forth herein establish the tenant selection guidelines for the TBRA program, provide the necessary operating structure for the program and clarify the roles and responsibilities of The Illumination Foundation and HIS House OC (Service Pr ovider) and the City.
I. MARKETING, OUTREACH AND APPLICATION PROCESS
I. Marketing and Outreach
The Service Provider is responsible for marketing and outreach activities to find prospective eligible households interested in the TBRA Program. It is anticipated that the primary source of applicants will be received from the Anaheim Union High School District (AUHSD) McKinney Vento Liaison for Illumination Foundation and from the City Net Community Care Response Team (CCRT) for HIS House OC.
Exhibit C – Page 2
The Service Provider will provide quarterly reports to the City that shall describe the marketing and outreach efforts for the quarter if requested.
2. Waiting List
Once the program has reached maximum enrollment, the Service Provider Illumination Foundation shall maintain a waiting list of prospective eligible households. This list will be prioritized as follows:
a. The client outcome matrix form; and
b. Most urgent need;
c. Date and time of referral to the Service Provider or initial direct contact with the Service Provider (if not a referral from another agency).
3. Intake Process
It is anticipated that most applicant households will be referred to the Illumination Foundation by the AUHSD and by CCRT or other community partner to HIS House OC. AUHSD referrals will include a completed client vulnerability index form.
For referrals that are provided by other community partners or received directly, the Service Provider will complete the vulnerability index form and will coordinate with the AUHSD to verify ties to Anaheim.
The Service Provider must attempt to contact the family within five (5) business days of the receipt of the referral. As part of the intake process, the Service Provider will meet with the prospective eligible household to conduct a needs assessment and complete an Initial Qualification Form (Appendix A). If the program has reached maximum capacity, the Service Provider shall review the referral to assess if other services may be offered while the applicant is waiting for a slot to open in the HAP-F program.
As part of the intake process, the Service Provider shall also request and/or assist the prospective eligible household with the completion of the following documents:
a. TBRA Application (Appendix B)
b. Declaration of Homelessness Status or At-Risk of Homelessness Status (Appendix C)
4. Guidance for Eligible Households
The Service Provider will meet with the prospective eligible households throughout the application process and will continue to meet with and counsel each eligible household regarding the TBRA Program, the eligible household's responsibilities as participants of the TBRA Program, and the goals and objectives of the TBRA Program.
Exhibit C – Page 2
II. DETERMINATION OF ELIGIBILITY
The HAP-F program combines the resources of the ESG and HOME programs. ESG funds are used for the delivery of supportive service and HOME funds are utilized for rental assistance. While it is intended for the supportive services and rental assistance components of the program to be available jointly, applicant
families must meet the eligibility qualifications of each program in order to receive the respective assistance. Eligibility for servic es offered by the HAP -F program shall adhere to the following selection criteria:
Income Eligible Household
• To receive services under the supportive services component of the HAP-F program, applicant households must meet ESG income eligibility requirements and have a total household income at or below the extremely-low (30% AMI) income limits.
• To receive rental assistance under the HOME funded portion of the HAP -F program, the applicant's total household income must be at or below 60% of the AMI. On a case by case basis, exceptions may be granted to households with incomes between 60% and 80% of the AMI. The Service Provider must obtain written approval from the City before rental assistance is provided to households above 60% AMI.
• Income limits for extremely -low, very -low and low income households are established annually for the HOME Program by HUD for the Orange County income limit area.
• Gross Annual Income shall be determined in accordance with 24 CFR part 5 (often referred to as the Section 8 definition), with the allowable inclusions and exclusions from income established at 24 CFR 5.611.
• Gross Annual Income means the gross amount of income from all sources, including assets, for all adult household members that is anticipated to be received prospectively during the 12- month period following the date of application and before any deductions are taken.
• The Service Provider will determine and verify eligibility for assistance under the HAP-F TBRA Program through the review of income source documents. As outlined in the revised HOME rules published in July 2013, applicants must provide evidence of income for the two (2) most recent months. Acceptable source documents include wage statements, check stubs, entitlement verification from another government agency and bank statements. The definition of income for the purposes of the HAP -F TBRA program are located 24 CFR 5.609.
• The Service Provider may also consider any likely changes in income when collecting income verification documentation.
• Initial income verifications are valid for 6 months. If admission into the HAP-F program takes longer than 6 months, income verifications must be updated and reevaluated. After initial verification, income re- certifications shall be conducted annually.
• Income verifications will be used for two purposes:
Exhibit C – Page 3
o To determine eligibility for services (ESG and HOME TBRA assistance). A determination of eligibility will be completed as part of the admissions process and thereafter annually.
o Income information will be used to establish the household's initial contribution toward rent, which shall be set at 30% of the household income. The household's initial contribution will remain unchanged for the first 60 days of assistance under the HOME TBRA program. Thereafter, rent will be adj usted in accordance with section IV below.
Current residents of the City of Anaheim
Due to the nature of the population served by the HAP -F TBRA program, it may not be possible to obtain traditional proof of residency documentation such as utility bills. The following documentation can be accepted to establish that an applicant household qualifies for the programs Anaheim live/work preference:
Documentation from an Anaheim City school that the children in the household have been enrolled in and attending the school for at least the last 90 days from the time of admission into the HAP -FHAPP TBRA program.
Documentation from a partner agency in the Anaheim Homeless Collaborative evidencing that the family is known to be chronically homeless in Anaheim.
Proof that the family's last place of stable residency was in the City of Anaheim. Verification from a landlord is acceptable.
Proof that an adult member of the household is working or has been recently hired to work in Anaheim.
Currently homeless or at-risk of homelessness
At-Risk of Homelessness refers to a household that is at risk of being evicted due to an economic hardship in paying rent or staying current with rent, as determined in accordance with the ESG Program.
Definition of homelessness is the same as under the ESG Program (24 CFR 576.2).
Includes at least one child
A child is defined as under 19 years of age.
The child must reside in the household at least 51% of the time.
Exhibit C – Page 4
Annual Eligibility Verification
The Service Provider will re -qualify each eligible household, including examination of source documentation, on an annual basis.
The Service Provider Illumination Foundation may request that a participating eligible household provide verification(s) more often than annually, as reasonably necessary to confirm continued qualification and eligibility for the TBRA Program.
The Service Provider will provide written notice to each Applicant stating whether the Applicant was determined to be eligible for assistance under the TBRA Program.
III. SELECTION OF HOUSING
I. Housing Unit Selection
Eligible households may elect to rent any housing unit in the City of Anaheim so long as the unit meets federal Housing Quality Standards (HQS) or such other standards as may be made applicable to the TBRA Program by HOME Program statutes and/or regulations, specifically including Uniform Physical Condition Standards (UPCS) and passes a rent reasonableness test. Due to the nature of the population served by the HAP-F program, it is expected that the Service Provider will assist eligible households with finding and selecting an appropriate housing unit that meets all program requirements.
While the Service Provider can refer eligible households to appropriate h ousing units, households may not be required to select a particular housing unit.
Rental assistance under the HAP -F program is only provided for housing units located in the City of Anaheim. Unincorporated area of Anaheim is excluded.
2. Occupancy Standards
The number of persons in each eligible household will determine the required unit type. Each household must comply with the two per bedroom plus one occupancy standard.
The following table provides the occupancy standards by unit type:
Unit Type Number in Household
One-Bedroom Unit Up to 3 Persons
Two-Bedroom Unit Up to 5 Persons
Three-Bedroom Unit Up to 7 Persons
Four-Bedroom Unit Up to 9 Persons
Exhibit C – Page 5
3. Property Inspections
Prior to occupancy of any housing unit by an eligible household, and again during the annual verification process, the Service Provider inspect each housing unit to ensure the unit complies with Housing Quality Standards (HQS) as set forth in the HOME Program (24 CFR 982.401(a)), as well as all applicable state and local codes and ordinances, including zoning ordinances.
Each HQS inspection will include the following:
• Verification of property ownership;
• Verification of the age of the housing unit;
• Completed HQS Inspection Form ( HUD -52580);
• Lead-based paint hazard assessment, dissemination of lead -based paint information pamphlet and disclosure form and lead -based paint reduction activities, if required;
• Adequate opportunity for landlord to correct any deficiencies indicated in the HQS Inspection form to bring the housing unit into compliance;
• Verification that occupancy by the eligible household will comply with occupancy standards;
4. Rent Reasonableness
Rental assistance paid on behalf of TBRA household must be in compliance with federal rent reasonableness requirements which require that rents paid by or on behalf of assisted households be similar to rents paid by non -assisted households.
Rent Reasonableness reviews will be performed by the Service Provider. The factors listed below shall be considered when determining rent comparability.
• Location and age
• Unit size including the number of rooms and square footage of rooms • The type of unit including construction type (e.g., single family, duplex, garden, low-rise, high-rise)
• The quality of the unit, which includes the building construction, maintenance and improvements
• Amenities, services, and utilities included in the rent
The Service Provider will follow both the rent reasonableness regulations established for the Housing Choice Voucher (HCV) program at 24 CFR 982.507 and the methodology described in Chapter 8, Part III of the Anaheim Housi ng Authority Administrative Plan for the HCV program to evaluate rents. In the event that a rent request does not meet rent reasonableness requirements, the
Service Provider shall attempt to negotiate a lower rent with the property owner. If t he owner is not willing to accept a lower rent, the household must be instructed to search for another unit. Under no circumstances shall the Service Provider or the assisted household agree to pay more than approved through the rent reasonableness r eview.
Additionally, the assisted household is not allowed to make up any difference in the rent offer.
Exhibit C – Page 6
The Anaheim Housing Authority (AHA) will provide support to the Service Provider in completing this task. AHA will be available for technical support and grant access to rent reasonableness data that Service Provider can use in finalizing approvals. In the event that there is a conflict between rents authorized by Service Provider and rents authorized for other rent subsidy programs of fered by the City of Anaheim, the Service Provider must work with AHA and/or City staff to resolve the conflict so that there is parity in all City sponsored rental assistance programs.
5. Coordination with Landlords
The Service Provider will meet with and provide guidance to landlords participating in the TBRA Program regarding the requirements and procedures that impact landlords.
Rental Assistance Contract (Appendix D)
• The Service Provider will enter into a Rental A ssistance Contract with each participating household. The Rental Assistance Contract will establish the security deposit assistance payment and the initial rental assistance payments to be paid on behalf of the household. The Contract will also establi sh the participating household's initial share of the contract rent.
• The household's share of rent will be adjusted using an escalation factor of $100 after 60 days of occupancy. The household's share may be further increased every 60 days thereafter.
• This Contract will have a term of up to 12 months.
Lease Addendum (Appendix E)
• The landlord will be required to enter into a lease agreement with a term of up to 12 months with any eligible household occupying a housing unit.
• The lease agreement will include a lease addendum that will be executed in connection with the lease between the landlord and the eligible household.
• The addendum will include the terms of the rental assistance payments to be paid to the landlord on behalf of the eligible household, confirm the obligations of the landlord, confirm obligations of the eligible household regarding payment of rent, utilities and appliances, rules and regulations of tenancy and confirm the landlord's obligation to maintain the housing unit in accordance with HQS.
• The landlord will be required to provide the Service Provider with notice of a lease termination, prohibit discrimination by the landlord against the eligible household as well as lease provisions prohibited by the HOME Program.
• The Service Provider will review the lease agreement to confirm its compliance with state law and all HOME Program requirements
Exhibit C – Page 7
IRS Form W-9 (Appendix F)
• Each landlord will be required to submit a completed IRS Form W-9 Request for Taxpayer Identification Number and Certification. The Service Provider will rely on this information when issuing a 1099 form to each payee as required by the IRS. A 1099 form must be issued annually to all participating landlord (payee).
IV. Payment Standards, Rent Calculation, Term and Subsidy Reductions
As authorized by HOME TBRA regulations, the HAP-F TBRA program will rely on a unique subsidy calculation model rather than traditional rental assistance calculations. The model allows for an initial rent subsidy determination that is based on 30% of household income but then increases every other month using an escalation factor of $100. The use of this rent subsidy calculation model has been recommended by the Service Provider based on their experience in working with the specific target population served by HAP-F. The escalation factor is used to encourage households to progress in their individual case management goals and to stay on track with objectives aimed at increasing household income. The Service Provider will closely monitor the use of the escalation factor and can waive the next scheduled rent escalation as needed.
Rent Assistance Calculation
The Service Provider will complete a rental assistance calculation for each eligible household.
The calculation will determine ea ch household's initial program subsidy and share of the rent.
The initial household rent is equivalent to the maximum subsidy amount allowed under HOME TBRA regulations and is calculated as the difference between 30% of the household's monthly income and the payment standard for the size of the unit. Each households maximum rent subsidy will vary since the calculation involves the use of individualized factors such as the household's income and family size.
The initial household rent will remain unchanged for the first 60 days of assistance. Thereafter, household rent contributions may be increased by $100 every other months. Once rent acceleration factors are applied, the household's rent contribution will no longer tie back to a percentage of household income.
Minimum rent under the TBRA program is set at $50.00. The minimum tenant payment is used if the maximum subsidy calculation would result in the household paying less than $50.00 towards the monthly rent.
Payment Standards
The TBRA program must use the Anaheim Housing Authority's (AHA) current payment standards (Appendix G) to calculate monthly rental assistance. The AHA's payment standards represent the cost of rent and utilities for moderately priced units in Anaheim. Paymen t standards are established by bedroom size.
When utilities are included in the cost of renting a unit, that is, the owner assumes responsibility for payment for all utility services, the household's entire share of the housing costs will go directly to the owner.
Exhibit C – Page 8
When the cost of utilities is not part of the rent, that is, the household is directly responsible for payment of utility services, the household's initial share will be determined by subtracting a utility allowance from 30% of the h ousehold's total income. The Service Provider must use the AHA utility allowance schedule (Appendix H) to determine the household's utility allowance.
The result of 30% of the household's total income minus the applicable utility allowance is the household's initial share of rent. Each household is responsible for paying their rent share directly to the landlord each month.
If a selected housing unit is subject to contractual, statutory and/or regulatory affordability restrictions, the monthly rental assistance payments will not exceed the difference between the required affordable rent amount for the Housing Unit and 30% of the eligible household's monthly gross income.
Term
The Service Provider will provide rental assistance for an initial term of 12 months, which can be extended in 3 month intervals , up to a total four times, for a cumulative term of 24 months. Extensions beyond the first 12 months will be granted at the discretion of the HAP-F program manager and shall require written approval which will be based on continued program compliance and ongoing need.
Written approval must be requested beyond the 12th month of rental assistance and obtained before reaching the 15th 18th, 21st, and/or 24th month term.
The Service Provider will utilize the Client Outcome Matrix Form (Appendix I) to evaluate ongoing need. Households that score between 0 - 80 on the client outcome matrix will be eligible for a subsidy extension.
Subsidy Reductions
During the first 60 days of occupancy in the new unit, the household's contribution toward rent will remain unchanged. Thereafter, every other month the rental assistance payment amount paid on behalf of the assisted household may be reduced by $100.00. When the rental assistance payment is reduced, the assisted household is responsible for making up the difference in the payment.
Households may request suspensions of their monthly rent increases. All requests will be reviewed by the Service Provider and granted at their sole discretion. In evaluating whether or not to grant a request to suspend a proposed rental assistance payment decrease the Service Provider shall consider the family's ability to make additional rental payments, extenuating life circumstances, unplanned expenses, and/ or unexpected loss of income. Suspensions of the monthly rent increases should be documented in client file with a written explanation of the hardship and a plan from the Service Provider Case Manager on steps being taken to help household overcome the financial hardship.
V. Utility and Security Deposits
Utility Deposit Assistance
The Service Provider may provide utility deposit assistance to an eligible household in the full amount of any utility deposit required for (electricity, gas and/or telephone service) to be provided to the utility provider when needed to assist the household in establishing a tenancy.
Exhibit C – Page 9
Utility Deposit Assistance may be provided only if the following requirements are met:
• Utility deposit assistance is only available where rental assistance is also being provided.
• Utility deposit assistance will be paid directly to the landlord or utility provider on behalf of the eligible household.
• Utility deposits that are provided to the participating households will be in the form of a grant. Utility deposit refunds can be returned directly to the assisted household
Security Deposit Assistance
As needed, the Service Provider will provide security deposit assistance to eligible households.
Such assistance shall be the lesser of;
1. Two months approved rent for the housing unit; or
2. The standard security deposit required by the Landlord for non -subsidized tenants.
Security deposit assistance provided to participating households will be in the form of a grant. As such , the landlord can provide a security deposit refund directly to the household. Any disputes involving the return, or lack thereof, of a security deposit shall be settled by the tenant and landlord, as provided for in the lease.
VI. Annual Re-certification, Termination of Assistance and Returning Households
Annual Recertification
Recertification of income and program el igibility will occur annually. The Service Provider will gather source documentation for participating households to determine annual income. Annual income must be calculated in accordance with 24 CFR part 5 .609.
If the total household income is above 80% AMI, rental assistance must be terminated following a 30 day notification period. For households between 60% and 80% AMI the Service Provider must obtain approval from the City before rental assistance is continued.
Termination of Rental Assistance
Assistance can be terminated for the following reasons:
• Failure to comply with HAP -F Program Guidelines and/ or Client Participation Agreements including disengagement in client services.
• Eviction from the assisted rental unit based on behavioral issues and/or unlawful activity.
• The participant no longer qualifies, based on income eligibility, for assistance at annual re- certification.
Exhibit C – Page 10
• The family will be assisted by another rental assistance program such as the Section 8 Tenant - Based or Project -based program. Participation in any other rental assistance program is considered a duplicative subsidy therefore all HOME funded rental assistance must terminate.
Returning Participant Households
As needed, participants may be allowed to return to the program for either support services, rental assistance or both. A determination to allow re- entry shall be based on the following criteria:
• Participants must have left the program in good standing. To be in good standing, participants must have been engaged in their case management plan , voluntarily left the program (not in lieu of termination) or have been released because their household income exceeded eligibili ty limits. In general, participants will not be allowed to re -enter the program if they were terminated for non-compliance.
• At the discretion of the Service Provider , a request for readmission from a non- compliant household may be considered when compelling reasons exist. In such cases, re-admission will require concurrence from the City of Anaheim.
• The participant's previous rental assistance did not exceeded 24 months. Cumulatively, participants will only be allowed to receive rental assistance for a maximum of 24 months.
VII. Self Sufficiency Program
The Service Provider will request each eligible household receiving rental assistance payments to participate in a Self -Sufficiency Program administered by the Service Provider . The Self- Su fficiency Program Policies and Procedures are outlined in Appendix J.
The Self Sufficiency Program provides participating households with intense case management, which is designed to assist participants move to self- sufficiency within a 12 to 24 month period.
Income re-certifications will be completed annually for participating households. If the participating household's income exceeds the extremely -low (30% AMI) income limits, the Service Provider must stop using ESG funds for the case management services and use another funding source to continue these services.
The family's failure to continue participation in the Self-Sufficiency Program is not a basis for terminating the assistance; however, households that fail to participate in the Self -Sufficiency Program will not be allowed to receive rental assistance extensions. Service Provider reserves the right to give client and landlord a “Notification of Non-renewal” if the client becomes non-responsive (see Section VI).
Exhibit C – Page 11
Listed below are some of the Self -Sufficiency Case Management Services offered by the Illumination Foundation:
Behavioral Health
Illumination Foundation provides every client serviced with a Behavioral Health assessment in order to appropriately connect clients with needed support based on life experience. Illumination Behavioral Health provides individual adult, individual child, couple, family and group counseling for no cost to the client.
Workforce Development
The Illumination Foundation Workforce Development Program provides life skills training, job skills, and employment placement to obtain and maintain employment. For 40- hours a week, clients are taught how to comply with workplace standards and how to excel in a professional environment.
During the last week of class clients attend a job fair and take part in a resume writing workshop with professional advisors, and mock interviews.
Medical
Illumination Foundation provides the homeless, uninsured, and underinsured access to medical care, vision care, and mental health services through a dedicated clinic and several remote neighborhood clinics.
Education
Illumination Foundation provides early childhood education and after -school programs for the homeless and at-risk children to overcome the effects of homelessness. The crisis prevention curriculum facilitates parent and child enrichment, financial literacy and life skills.
Listed below are some of the Self -Sufficiency Case Management Services offered by HIS House OC
Combined Housing, Education, and Skills for Students (CHESS): Our CHESS program began in 2020 when HIS-OC’s staff and board recognized a need to provide services for single men in Orange County aged 18-24 and transitioning to adulthood. The young men in our program participate in programming emphasizing education and life skills, offering a safe place to live while pursuing an education and transitioning to self-sufficiency. In addition to trauma- informed service navigation, the CHESS program
guides young people to complete college courses or job training programs, secure better grades, obtain employment, acquire life skills, and save money.
Resource Connections: Operating out of two community centers in Placentia, CA, HIS-OC provides referral services for all HIS-OC clients in the North Orange County SPA as well as walk-ins from the local neighborhoods.
HAP-F clients will be referred to and encouraged to utilize the classes and resources including financial literacy, self- care classes, parenting classes, after-school tutoring, and transportation support including bus passes, Uber cards, Veyo (depending on availability).
Case Managers and Resource Specialists will ensure clients are kept abreast of classes and event opportunities that include health and wellness fairs, job fairs, MediCal enrollment workshops, Cal-Works support, food and holiday gift distributions. All Resource Connection offerings are in addition to the standard case management practices which bring wraparound health, financial, documentation, job assistance, childcare connections, and more resources.
If additional services and resources are needed, the participants will be referred to outside agencies.
Appendix A
APPENDIX A
INITIAL QUALIFICATION FORM
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Appendix A
HAP – F
Initial Qualification Document
Appendix A – Page 1
Applicant #1 Name: _________________________________________________ Birth Date: ___/___/______
Applicant #2 Name: _________________________________________________ Birth Date: ___/___/______
Child #1 Name: ______________________________________________________ Birth Date: ___/___/______
Child #2 Name: ______________________________________________________ Birth Date: ___/___/______
Child #3 Name: ______________________________________________________ Bir th Date: ___/___/______
Child #4 Name: ______________________________________________________ Birth Date: ___/___/______
Household Size _______________
FY 2022* Income Limits Summary
HUD Income Limits
*updated annually
Family Size Extremely Low Income
30% AMI
Very Low Income
50% AMI
Low Income
80% AMI
1 $28,500 47,450 75,900
2 $32,550 54,200 86,750
3 $36,600 61,000 97,600
4 $40,650 67,750 108,400
5 $43,950 73,200 117,100
6 $47,200 78,600 125,750
7 $50,450 84,050 134,450
Source of Income: ______________________________________Monthly Gross Income$_______________
Yearly Gross Income $ _______________
☐Household is eligible to participate in the __________ program under the Program Income Limits.
☐Household is not eligible to participate in the _________ program under the Program Income Limits.
Provide a letter to the household stating the reasons for ineligibility.
____________________________________ ___________________________________ Client Signature and Date Intake staff Signature and Date
___________________________________________ ___ ________________________________________ Christine Stellino, Director of Family Date
Program
Appendix B
APPENDIX B
TBRA APPLICATION
[Behind this page.]
Appendix B
Homeless Assistance Program for Families (HAP-F)
Program Application
Appendix B – Page 1
Tell the whole truth. Leaving out information may cause your application to be delayed or rejected. Giving false information may lead to criminal prosecution or permanent denial of all federal assistance.
Application Procedure
If you believe you qualify for HAP-F program assistance, you will need to provide the following documents for all adults in the household. Incomplete applications will not be accepted. We do not return documents turned into us so be sure to give us only copies of your documents.
Completed applications may be submitted by mail or drop-off to: (insert service provider name and address) or by Fax: (insert fax number)
1. Housing Assistance Program for Families Application
2. Government-issued photo identification (driver’s license, etc.) of all adult household members
3. Proof of child enrollment in Anaheim Schools (if applicable)
4. 2 months proof of income (pay stub, copy of social security check, etc.)
5. 3 months proof of assets (most recent checking, savings, investment statements, etc.)
6. Documentation of housing status
a. If you are homeless: Documentation from a homeless shelter, other evidence of homelessness (motel receipts, or self-certification of homelessness b. If you are currently housed but have received a 3 day notice to pay or quit, please provide a copy of this document.
Appendix B
Homeless Assistance Program for Families (HAP-F)
Program Application
Appendix B – Page 2
Applicant’s Information
Adult #1
Last Name:
First Name: M.I.: Gender:
F or M
DOB:
____/____/_____
SSN: Driver’s License or Identification Number/State:
Phone Number: E-mail Address:
Adult #2
Last Name:
First Name: M.I. Gender:
F or M
DOB:
____/____/_____
SSN: Driver’s License or Identification Number/State:
Phone Number: E-mail Address:
Adult #3
Last Name:
First Name: M.I. Gender:
F or M
DOB:
____/____/_____
SSN: Driver’s License or Identification Number/State:
Phone Number: E-mail Address:
Most Recent Street Address: Apartment/Unit #:
City: State: Zip:
Most Recent Landlord Name and Phone Number:
Reference (employer, community member) Name:
Phone:
Date you moved into your current address:
Have you lived in Orange County for the last six months? YES NO; If so, what proof do you have?
How did you hear about HIS OC? Who referred you?
Children’s Information (Please list all children)
Full Name of Child Social Security
Number
Gender Date of Birth Age Living with
You?
School or Childcare
Program and City
F or M Y or N
F or M Y or N
F or M Y or N
F or M Y or N
Appendix B
Homeless Assistance Program for Families (HAP-F)
Program Application
Appendix B – Page 3
Employment Information for Adult #1
Company: Phone Number:
Address: Supervisor:
Job Title: Wage and Hours per Week:
Responsibilities:
Employment Information for Adult #2
Company: Phone Number:
Address: Supervisor:
Job Title: Wage and Hours per Week:
Responsibilities:
Employment Information for Adult #3
Company: Phone Number:
Address: Supervisor:
Job Title: Wage and Hours/Week:
Responsibilities:
Re-Housing Questions
Do you have pets? YES NO; If so, what kind and how big are they? Does anyone in the household smoke?
Do you receive rental assistance or section 8?
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge. If this application leads to participation in the housing program, I understand that false or misleading information in my application or interview may result in my termination from the program.
F or M Y or N
Appendix B
Homeless Assistance Program for Families (HAP-F)
Program Application
Appendix B – Page 4
Adult #1 Signature: Date:
Adult #2 Signature: Date:
Adult #3 Signature: Date:
Release of Information
CLIENT/PROVIDER INFORMATION:
Client’s Name:
Date of Birth:
Social Security Number: Telephone Number:
Provider:
Provider:
Provider:
Provider:
Pursuant to Federal Guidelines concerning my right to confidentiality, I hereby authorize the:
USE RELEASE EXCHANGE
From: To: Landlord/Property Manager
Employer
Specific nature, extent, and dates of information requested:
Discuss client’s situation and needs, rent & security deposits. Etc.
Reason for request:
Confirm information provided and needed
I understand that I may revoke this consent of release of information at any time. I also understand, however, that any release which has been made prior to my revocation Appendix B
Homeless Assistance Program for Families (HAP-F)
Program Application
Appendix B – Page 5
and which was made in reliance upon this authorization shall not constitute a breach of my right to confidentiality. Unless I revoke this authorization in writing, prior to such time, this authorization to release information shall expire one year from the signature date below. At that time, no express revocation shall be needed to terminate my consent.
Signature: _______________________________ Today’s Date: ________________ Printed Name: _________________________________________________________
Complete Address: ____________________________________________________ Telephone Number: ________________________________________________
HAP-F Disclaimer & Notice of Responsibility
Homeless Intervention Services of OC (HIS-OC) is a non-profit agency that is authorized to distribute federal rental assistance through the Housing Assistance Program for Families (HAP-F)
The following applicant(s) for the HAP-F program:
Name: ______________________________________________________________________ Name: ______________________________________________________________________ Name: ______________________________________________________________________ Understand and agree to the following terms and conditions 1) All applicants are screened to ensure the highest probability that they will be able to maintain rental payments on their own and within their budget. 2) No guarantee of assistance is being offered by HIS-OC. You are still responsible for your own rent and utility payments while your application is being processed.
3) It is the responsibility of the applicants, not HIS-OC, to keep their landlord and other debtors updated on the status of their potential assistance and ability to pay.
4) HIS-OC will deny any application that contains false information. 5) Applicants understand that their personal information is being entered in a central database to monitor and track assistance applied for, and when applicable, awarded.
Appendix B
Homeless Assistance Program for Families (HAP-F)
Program Application
Appendix B – Page 6
Signature: __________________________________________ Date: ___________________ Signature: __________________________________________ Date: ___________________ Signature: __________________________________________ Date:___________________
Appendix B
Homeless Assistance Program for Families (HAP-F)
Program Application
Appendix B – Page 7
We/I, ________________________ and , and our children are currently applying to or are participants in the Housing Assistance Program for Families. We understand that during our application process and during program participation, confidential information will be requested in order to assess the needs of and provide appropriate services to our family.
We acknowledge that HIS-OC maintains a policy of respecting a client’s right to privacy and confidentiality. In an effort to achieve this, HIS-OC keeps paper and electronic client records in locked file cabinets and in a secure database. Also, HIS-OC only shares information on a need-to-know basis with appropriate staff and other authorized professionals.
We understand that all information we provide to HIS-OC staff is confidential within the organization.
However, we understand that, according to California law1 and legal precedent2, all staff are mandated reporters and are legally required to share confidential information about our family with or without our permission under the following circumstances:
• If staff has any suspicion that a child or an elderly or dependent adult is being abused or neglected.
• If staff determine that anyone in our family is a danger to his/her self or to another person(s).
Under these circumstances, staff has the legal responsibility to breach our confidentiality to insure the safety of the individual(s) at risk. Should disclosure or reasonable suspicion of the stated above occur, we are aware that staff will contact the appropriate agencies/individuals including, but not limited to, the police, child protective services, adult protective services and/or the person at risk.
By signing below, we indicate that we have read, understood, and agree to comply with HIS-OC’s policy
on confidentiality and its limitations. Furthermore, we are aware of HIS-OC’s policy regarding information sharing for collaboration purposes, and we understand that our confidential information, with the exceptions stated above, cannot be released without written consent. We have the right to receive a copy of this document if requested, and a photocopy of this document is as valid as the original
Adult #1 Signature Date
Print Name
Adult #2 Signature Date
Print Name
1 Child Abuse and Neglect Reporting Act, Sections 11164-11174.3; Welfare and Institutions Code, Sections 11166, 15630.9 and 15610.07 2 Tarasoff vs. Regents of the University of California
Appendix C
APPENDIX C
DECLARATION OF HOMELESSNESS
[Behind this page.]
Appendix C – Page 1
HOUSING ASSISTANCE PROGRAM FOR FAMILIES (HAP-F)
EMERGENCY SOLUTIONS GRANT
HUD’s DEFINITION of HOMELESSNESS and CERTIFICATION
Household Name: ______________________________________________ Date: __________________ This is to certify the above individual or household is currently homeless based on the category checked and required documentation. **THE GENERAL HOMELESS CERTIFICATION MUST BE COMPLETED FOR EACH HOUSEHOLD.
CHRONICALLY HOMELESS CERTIFICATION
CHRONICALLY HOMELESS: (If chronically homeless, the General Homeless Certification Category 1, must also be completed).
Individual or family:
(i) Has been homeless and living or residing in a place not meant for human habitation, a safe haven, or in an emergency shelte r continuously for at least one year or on at least four separate occasions in the last three years; and (ii) Has an adult head of household (or a minor head of household if no adult is present in the household) with a diagnosable substance use disorder, serious mental illness, developmental disability (as defined in Section 102 of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15002)), post-traumatic stress disorder, cognitive impairments resulting from a brain injury, or chronic physical illness or disability, including the co -occurrence of 2 or more of those conditions.
**GENERAL HOMELESS CERTIFICATION
**Category 1 is eligible for Rapid Re-housing Assistance CATEGORY 1: Literally Homeless
Individual or family who lacks a fixed, regular, and adequate nighttime residence, meaning:
(i) Has a primary nighttime residence that is a public or private place not meant for human habitation; or (ii) Is living in a publicly or privately operated shelter designated to pr ovide temporary living arrangements (including congregate shelters, transitional housing, and hotels and motels paid for by charitable organizations or by federal, state and local government programs).
To certify homeless status for the above, must provide documentation of 1 of the following:
Written observation by the outreach worker; or
Written referral by another housing or service provider; or Certification by the individual or head of household seeking assistance stating that (s)he was living on the streets or in shelter (Form No. 5).
Individual or family who lacks a fixed, regular, and adequate nighttime residence, meaning:
(iii) Is exiting an institution where (s)he has resided for 90 days or less and who resided in an emergency shelter or place not meant for human habitation immediately before entering that institution (documentation must include one of the above forms of evidence AND 1 of the following).
Discharge paperwork or written/oral referral; or
Written record of intake worker’s due diligence to obtain above evidence and certification by individual that they exited institution (Form No. 5).
**Ca tegories 2 thru 4 are considered “homeless” but receive assistance under Prevention CATEGORY 2: Imminent Risk of Homelessness
Individual or family who will imminently lose their primary nighttime residence, provided that:
(i) Residence will be lost within 14 days of t he date of application for homeless assistance; (ii) No subsequent residence has been identified; and
(iii) The individual or family lacks the resources or support networks needed to obtain other permanent housing .
Appendix C
Appendix C – Page 2
HUD’s DEFINITION of HOMELESSNESS and CERTIFICATION
CATEGORY 2: Imminent Risk of Homelessness (continued)
Documentation must include 1 of the following:
A court order resulting from an eviction action notifying the individual or family that they must leave; or For individual and families leaving a hotel or motel—evidence that they lack the financial resources to stay (Form No. 5); or
A documented and verified oral statement.
In addition to 1 of the above, documentation must include BOTH of the following:
Certification that no subsequent residence has been identified (Form No. 5); AND Self-certification or other written documentation that the individual lack the financial resources and suppor t necessary to obtain permanent housing (Form No. 5).
CA
TEGORY 3: Homeless under Other Federal Statutes
Unaccompanied youth under 25 years of age, or families with children and youth, who do not otherwise qualify as homeless under this definition, but who:
( i) A re defined as homeless under the other listed federal statutes; (ii) H
ave not had a lease, ownership interest, or occupancy agreement in permanent housing during the 60 days prior to the homeless assistance application;
(iii) H ave experienced persistent instability as measured by 2 moves or more during the preceding 60 days; and (iv) Can be expected to continue in such status for an extended period of time due to special needs or barriers.
Documentation must include all of the following:
Certification by the nonprofit or state or local government that the individual or head of household seeking assistance met the criteria of homelessness under another federal statute; and Certification of no public housing in the last 60 days; and Certification by the individual or head of household, and any available supporting documentation, that (s)he has moved 2 or more times in the past 60 days; and
Documentation of special needs or 2 or more barriers.
CA
TEGORY 4: Fleeing/Attempting to Flee Domestic Violence Any individual or family who:
(i) Is fleeing, or is attempting to flee, domestic violence; (ii) Has no other residence; and
(iii) L acks the resources or support networks to obtain other permanent housing Documentation required:
For victim service providers:
An oral statement by the individual or head of household seeking assistance which states: they are fleeing; they have no subsequent residence; and they lack resources. Statement must be documented by a self -certification (Form No. 5) or a certification by the intake worker.
For non-victim service provider (must document all of the following):
O ral statement by the individual or head of household seeking assistance that they are fleeing. This statement is documented by a self-certification (Form No. 5) or by the caseworker. Where the safety of the individual or family is not jeopardized, the oral statement must be verified; and Certification by the individual or head of household that no subsequent residence has been identified (Form No. 5); and
Self-certification, or other written documentation, that the individual or family lacks the financial resources and support networks to obtain other permanent housing (Form No. 5).
Appendix C – Page 3
Intake Staff Signature: ________________________________________ Date: ________________ Appendix D
APPENDIX D
RENTAL ASSISTANCE CONTRACT
[Behind this page.]
Appendix D
HAP-F
HOME RENTAL ASSISTANCE CONTRACT
LANDLORD NAME & ADDRESS
Telephone No. ________________
UNIT NO. & ADDRESS TENANT NAME
This HOME Rental Assistance Contract ("Contract") is entered into between the "City of Anytown, Department of " (program administrator) and the Landlord identified above. This Contract applies only to the Tenant family and the dwelling unit identified above.
1. TERM OF THE CONTRACT
The term of this Contract shall begin on
1 and end no later than .2 The
Contract automatically terminates on the last day of the term of the Lease.
2. SECURITY DEPOSIT3
A. The (program administrator) will pay a security deposit to the Landlord in the amount of $__________. The Landlord will hold this security deposit during the period the Tenant occupies the dwelling unit under the Lease. The Landlord shall comply with state and local laws regarding interest payments on security deposits.
B. After the Tenant has moved from the dwelling unit, the Landlord may, subject to state and local law, use the security deposit, including any interest on the deposit, as reimbursement for rent or any other amounts payable by the Tenant under the Lease. The Landlord will give the Tenant a written list of all items charged against the security deposit and the amount of each item. After deducting the amount used as reimbursement to the Landlord, the Landlord shall promptly refund the full amount of the balance to the [Tenant/program administrator].
C. The Landlord shall immediately notify the (program administrator) when the Tenant has moved from the Contract unit.
3. RENT AND AMOUNTS PAYABLE BY TENANT AND (program administrator)
A. Initial Rent. The initial total monthly rent payable to the Landlord for the first twelve months of this Contract is $______________.
B. Rent Adjustments. With no less than
4 days' notice to the Tenant and the (program
administrator), the owner may propose a reasonable adjustment to be effective no earlier than the 13th month of this Contract. The proposed rent may be rejected by either the Tenant or the (program administrator). The Tenant may reject the proposed rent by providing the Landlord
1 Insert the first day of the term of the Lease.
2 The maximum allowable length of a HOME Coupon Contract is two years. 3 Modify the paragraph based on PJ policy.
4 Insert the number of days notice the owner must provide of a rent increase. At least 60 days is recommended to enable the program administrator 30 days to review the rent and still enable the landlord to give the tenant 30 days notice.
HOME Rental Assistance Contract (Page Two)
with 30 days' written notice of intent to vacate. If the program administrator rejects the proposed rent, the program administrator must give both the Tenant and the Landlord 30 days' notice of intent to terminate the Contract.
C. Tenant Share of the Rent. Initially, and until such time as both the Landlord and the Tenant are notified by the (program administrator), the Tenant's share of the rent shall be $_______________.
D. Program Administrator Share of the Rent. Initially, and until such time as both the Landlord and Tenant are notified by the (program administrator), the (program administrator's) share of the rent shall be $_______________. Neither the (program administrator) nor HUD assumes any obligation for the Tenant's rent, or for payment of any claim by the Owner against the Tenant.
The (program administrator's) obligation is limited to making rental payments on behalf of the Tenant in accordance with this Contract.
E. Payment Conditions. The right of the owner to receive payments under this Contract shall be subject to compliance with all of the provisions of the Contract. The Landlord shall be paid under this Contract on or about the first day of the month for which the payment is due. The Landlord agrees that the endorsement on the check shall be conclusive evidence that the Landlord received the full amount due for the month, and shall be a certification that:
1. the Contract unit is in decent, safe and sanitary condition, and that the Landlord is providing the services, maintenance and utilities agreed to in the Lease.
2. the Contract unit is leased to and occupied by the Tenant named above in this Contract.
3. the Landlord has not received and will not receive any payments as rent for the Contract unit other than those identified in this Contract.
4. to the best of the Landlord's knowledge, the unit is used solely as the Tenant's principal place of residence.
F. Overpayments. If the (program administrator) determines that the Landlord is not entitled to any payments received, in addition to other remedies, the (program administrator) may deduct the amount of the overpayment from any amounts due the Landlord, including the amounts due under any other Rental Assistance Coupon Contract.
4. HOUSING QUALITY STANDARDS AND LANDLORD-PROVIDED SERVICES
A. The Landlord agrees to maintain and operate the Contract unit and related facilities to provide decent, safe and sanitary housing in accordance with 24 CFR Section 882.109, including all of the services, maintenance and utilities agreed to in the Lease.
B. The (program administrator) shall have the right to inspect the Contract unit and related facilities at least annually, and at such other times as may be necessary to assure that the unit is in decent, safe, and sanitary condition, and that required maintenance, services and utilities are provided.
C. If the (program administrator) determines that the Landlord is not meeting these obligations, the program administrator shall have the right, even if the Tenant continues in occupancy, to terminate payment of the (program administrator's) share of the rent and/or terminate the Contract.
5. TERMINATION OF TENANCY
The Landlord may evict the Tenant following applicable state and local laws. The Landlord must give the Tenant at least 30 days' written notice of the termination and notify the (program administrator) in writing when eviction proceedings are begun. This may be done by providing the (program administrator) with a copy of the required notice to the tenant.
HOME Rental Assistance Contract (Page Three)
6. FAIR HOUSING REQUIREMENTS
A. Nondiscrimination. The Landlord shall not, in the provision of services or in any other manner, discriminate against any person on the grounds of age, race, color, creed, religion, sex, handicap, national origin, or familial status. The obligation of the Landlord to comply with Fair Housing Requirements insures to the benefit of the United States of America, the Department of Housing and Urban Development, and the (program administrator), any of which shall be entitled to involve any of the remedies available by law to redress any breach or to compel compliance by the Landlord.
B. Cooperation in Quality Opportunity Compliance Reviews. The Landlord shall comply with the (program administrator) and with HUD in conducting compliance reviews and complaint investigations pursuant to all applicable civil rights statutes, Executive Orders and all related rules and regulations.
7. (Program administrator) AND HUD ACCESS TO LANDLORD RECORDS
A. The Landlord shall provide any information pertinent to this Contract which the (program administrator) or HUD may reasonably require.
B. The Landlord shall permit the (program administrator) of HUD, or any of their authorized representatives, to have access to the premises and, for the purposes of audit and examination, to have access to any books, documents, papers, and records of the Landlord to the extent necessary to determine compliance with this Contract.
8. RIGHTS OF (Program administrator) IF LANDLORD BREACHES THE CONTRACT
A. Any of the following shall constitute a breach of the Contract:
(1) If the Landlord has violated any obligation under this Contract; or
(2) If the Landlord has demonstrated any intention to violate any obligation under this Contract; or
(3) If the Landlord has committed any fraud or made any false statement in connection with the Contract, or has committed fraud or made any false statement in connection with any Federal housing assistance program.
B. The PHA's right and remedies under the Contract include recovery of overpayments, termination or reduction of payments, and termination of the Contract. If the (program administrator) determines that a breach has occurred, the program administrator may exerc ise any of its rights or remedies under the Contract. The (program administrator) shall notify the Landlord in writing of such determination, including a brief statement of the reasons for the determination. The notice by the PHA to the landlord may require the Landlord to take corrective action by a time prescribed in the notice.
C. Any remedies employed by the (program administrator) in accordance with this Contract shall be effective as provided in a written notice by the (program administrator) to the Landlord. The (program administrator's) exercise or non-exercise of any remedy shall not constitute a waiver of the right to exercise that or any other right or remedy at any time.
HOME Rental Assistance Contract (Page Four)
9. PHA RELATION TO THIRD PARTIES
A. The (program administrator) does not assume any responsibility for, or liability to, any person injured as a result of the Landlord's action or failure to act in connection with the implementation of this Contract, or as a result of any other action or failure to act by the Landlord.
B. The Landlord is not the agent of the (program administrator) and this Contract does not create or affect any relationship between the (program administrator) and any lender to the Landlord, or any suppliers, employees, contractors or subcontractors used by the Landlord in connection with this Contract.
C. Nothing in this Contract shall be construed as creating any right of the Tenant or a third party (other than HUD) to enforce any provision of this Contract or to asses any claim against HUD, the (program administrator) or the Landlord under this Contract.
10. CONFLICT OF INTEREST PROVISIONS
A. No employee of the (program administrator) who formulates policy or influences decisions with respect to the Rental Assistance Program, and no public official or member of a governing body or state of local legislator who exercise his functions or responsibilities with respect to the program shall have any direct or indirect interest during this person's tenure, or for one year thereafter, in this contract or in any proceeds or benefits arising from the Contract or to any benefits which may arise from it.
11. TRANSFER OF THE CONTRACT
The Landlord shall not transfer in any form this Contract without the prior written consent of the (program administrator). The (program administrator) shall give its consent to a transfer if the transferee agrees in writing (in a form acceptable to the (program administrator)) to comply with all terms and conditions of this Contract.
12. ENTIRE AGREEMENT: INTERPRETATION
A. This Contract contains the entire agreement between the Landlord and the program administrator. No changes in this Contract shall be made except in writing signed by both the Landlord and the (program administrator).
B. The Contract shall be interpreted and implemented in accordance with HUD requirements.
HOME Rental Assistance Contract (Page Five)
13. WARRANTY OF LEGAL CAPACITY AND CONDITION OF UNIT
A. The Landlord warrants the unit is in decent, safe, and sanitary condition as defined in 24 CFR Section 882.109, and that the Landlord has the legal right to lease the dwelling unit covered by this Contract during the Contract term.
B. The party, if any, executing this Contract on behalf of the Landlord hereby warrants that authorization has been given by the Landlord to execute it on behalf of the Landlord.
Landlord Name (Type or Print): (Program administrator) Representative (Type of Print):
(Signature/Date) (Signature/Date)
WARNING: 18 U.S.C. 1001 provides, among other things, that whoever knowingly and willingly makes or uses a document or writing containing any false, fictitious, or fraudulent statements or entries, in any matter within the jurisdiction of any department or agency of the United States, sha ll be fined not more than $10,000, or imprisoned for not more than five years, or both.
LANDLORD'S CHECK TO BE MAILED TO: SS NO. __________________________________
NAME(S)______________________________________________________________ _______
ADDRESS______________________________ _____________________________________
____________________________________________
SIGNATURE OF OWNER DATE
_____________________________________ ___
SIGNATURE OF OWNER DATE
RENT REASONABLENESS CHECKLIST AND CERTIFICATION
Proposed Unit Unit #1 Unit #2 Unit #3
Address
Number of Bedrooms
Square Feet
Type of Unit/Construction
Housing Condition
Location/Accessibility
Amenities
Unit:
Site:
Neighborhood:
Age in Years
Utilities (type)
Unit Rent
Utility Allowance
Gross Rent
Handicap Accessible?
CERTIFICATION:
A. Compliance with Payment Standard
____________________ _____________ __________________ Proposed Contract Rent + Utility Allowance = Proposed Gross Rent
Approved rent does not exceed applicable Payment Standard of $_____________.
B. Rent Reasonableness
Based upon a comparison with rents for comparable units, I have determined that the proposed rent for the unit [ ]is [ ] is not reasonable.
Name: Signature: Date:
Appendix E
APPENDIX E
LEASE ADDENDUM
[Behind this page.]
Appendix E
HAP-F Tenant Based Rental Assistance (TBRA)
LEASE ADDENDUM
Appendix E – Page 1
Administrator: Client Case Number: (as assigned in Neighborly Software) Administrator Address: Phone:
Tenant Name:
Unit Address: Number of Bedrooms:
Landlord Name:
Landlord Address: Phone:
Purpose of Lease Addendum . Tenant has been approved to receive rental assistance under the HOME Investment Partnerships (HOME) Program Tenant-Based Rental Assistance (TBRA) Activity administered by Administrator on behalf of the City of Anaheim. The Lease for the above-referenced rental unit is hereby amended to include the provisions of this Lease Addendum, as follows:
1. Conflict with Other Provisions of the Lease . In the event of any conflict between the provisions of this Lease Addendum and any sections of the Lease, the provisions of this Lease Addendum prevail.
2. Terms of Lease. The rental term of the Lease begins on:
/ / and terminates on / / , unless it is terminated sooner by one of the following events:
A. The Lease is terminated by Landlord in accordance with applicable state and local laws; or
B. The Lease is terminated by Tenant in accordance with the Lease; or C. The Lease is terminated by mutual agreement of Landlord and Tenant during the term of the Lease; or
D. The HOME Rental Assistance Contract between Tenant and Admini strator is terminated.
3. Rental Assistance Payment. The Program Administrator will provide rental assistance for an initial term of up to 12 months, which can be extended for additional periods of up to 3 months each, up to a total, cumulative term not to exceed 24 months in a three year period, all at the discretion of the Program Administrator. The initial total monthly rent payable to the Landlord for the first two months of this Lease Addendum is $____________________.
A. Payment Conditions. The right of the owner to receive payments under this Lease Addendum shall be subject to compliance with all of the provisions of the Lease. The Landlord shall be paid under this Lease Addendum on or about the first day of the month for which the payment is due. The Landlord agrees that the endorsement on the check Appendix E
HAP-F Tenant Based Rental Assistance (TBRA)
LEASE ADDENDUM
Appendix E – Page 2
shall be conclusive evidence that the Landlord received the full amount due for the month, and shall be a certification that:
1. the Lease unit is in decent, safe and sanitary condition, and that the Landlord is providing the services, maintenance and utilities agreed to in the Lease.
2. the Lease unit is leased to and occupied by the Tenant named above in this Lease Addendum.
3. the Landlord has not received and will not receive any payments as rent for the Lease unit other than those identified in this Lease Addendum.
4. to the best of the Landlord's knowledge, the unit is used solely as the Tenant's principal place of residence.
B. Overpayments. If the Program Administrator determines that the Landlord is not entitled to any payments received, in addition to other remedies, the Program Administrator may deduct the amount of the overpayment from any amounts due the Landlord, including the amounts due under any other Rental Assistance Contract.
4. Security Deposit.
A. Administrator has paid: $_________________ directly to Landlord to be held as a Security Deposit paid on behalf of Tenant. Landlord will hold the Security Deposit during the period in which Tenant occupies the rental unit under the Lease. Landlord will comply with state and local laws regarding interest earned on Security Deposits.
B. After Tenant's household has vacated the rental unit, Landlord may use the Security Deposit as reimbursement for rent or toward any other amounts payable by Tenant under the Lease, in accordance with state and local laws. Landlord will provide Tenant a written list specifying all damages, items, and amounts charged against the Security Deposit. Any Security Deposit amount remaining after the reimbursement to Landlord has been deducted shall be promptly refunded directly to Tenant.
C. The Landlord shall immediately notify the Program Administrator whe n the Tenant has moved from the Leased unit.
5. Utilities and Appliances. Utilities and appliances are provided as indicated in the following table:
Description of
Utility or Appliance Included in Rent? Paid for or Provided by Heating (specify type)
☐ Electric ☐ Gas ☐ Oil
☐ Yes ☐ No ☐ Landlord ☐ Tenant
Air Conditioning ☐ Yes ☐ No ☐ Landlord ☐ Tenant
Appendix E
HAP-F Tenant Based Rental Assistance (TBRA)
LEASE ADDENDUM
Appendix E – Page 3
Cooking (specify type)
☐ Electric ☐ Gas
☐ Yes ☐ No ☐ Landlord ☐ Tenant
Other Electric ☐ Yes ☐ No ☐ Landlord ☐ Tenant
Water Heating (specify type)
☐ Electric ☐ Gas
☐ Yes ☐ No ☐ Landlord ☐ Tenant
Water ☐ Yes ☐ No ☐ Landlord ☐ Tenant
Sewer ☐ Yes ☐ No ☐ Landlord ☐ Tenant
Trash Collection ☐ Yes ☐ No ☐ Landlord ☐ Tenant
Range ☐ Yes ☐ No ☐ Landlord ☐ Tenant
Refrigerator ☐ Yes ☐ No ☐ Landlord ☐ Tenant
Other: ☐ Yes ☐ No ☐ Landlord ☐ Tenant
6. Household Members. ALL Household members authorized to live in this rental unit are listed below. Tenant may not permit other persons to join the household without notifying Administrator and obtaining Landlord's permission.
Full names of ALL household members:
1. 5.
2. 6.
3. 7.
4. 8.
7. Housing Quality Standards. The Landlord agrees to maintain and operate the Lease unit and related facilities to provide decent, safe and sanitary housing in accordance with 24 CFR Section 882.109, including all of the services, maintenance and utilities agreed to in the Lease.
The Program Administrator shall have the right to inspect the Lease unit and related facilities at least annually, and at such other times as may be necessary to assure that the unit is in decent, safe, and sanitary condition, and that required maintenance, services and utilities are provided.
If the Program Administrator determines that the Landlord is not meeting these obligations, the Program Administrator shall have the right, even if the Tenant continues in occupancy, to terminate payment of the Program Administrator's share of the rent and/or terminate the Lease.
Appendix E
HAP-F Tenant Based Rental Assistance (TBRA)
LEASE ADDENDUM
Appendix E – Page 4
8. Termination of Tenancy. Landlord may evict Tenant for cause in accordance with HOME Program requirements and applicable state and local statute. Landlord must provide all required notices to Tenant and provide copies of such notices to Administrator. Landlord must notify Tenant and Administrator in writing when eviction proceedings begin.
9. Prohibited Lease Provisions. The following provisions may not be included in or applied to the Lease, and may not be enforced by Landlord:
A. Confession of Judgment. Tenant may not be required to consent to be sued, to admit guilt, or to accept or acknowledge a judgment in favor of Landlord in a lawsuit brought in connection with the Lease.
B. Treatment of Property. Tenant may not be required to agree that Landlord may take or hold Tenant's property, or sell such property without notice to Tenant and a court decision on the rights of the parties.
C. Excusing Landlord from Responsibility . Tenant may not be required to excuse Landlord or Landlord's agent from his/her legal responsibility for any action or failure to act, whether intentional or negligent.
D. Waiver of Legal Notice . Tenant may not be required to agree that Landlord may institute a lawsuit without notice to Tenant.
E. Waiver of Court Proceedings for Eviction. Tenant may not be required to agree that Landlord may evict Tenant and/or Tenant's family prior to:
i. the initiation of civil court proceedings in which the family has the opportunity to present a defense; or
ii. the receipt of a decision by the court on the rights of the parties.
F. Waiver of Jury Trial . Tenant may not be required to authorize Landlord to waive Tenant's right to a trial by jury.
G. Waiver of Right to Appeal Court Decision. Tenant may not be required to authorize Landlord to waive Tenant's right to appeal a court decision or waive Tenant's right to sue to prevent a judgment from being put into effect.
H. Tenant Chargeable with Cost of Legal Actions Regardless of Outcome of the Lawsuit.
Tenant may not be required to agree to pay attorney fees or other legal costs in the event Landlord files civil suit.
I. Mandatory supportive services . Landlord may not require agreement by the tenant (other than a tenant in transitional housing) to accept supportive services that are offered.
Appendix E
HAP-F Tenant Based Rental Assistance (TBRA)
LEASE ADDENDUM
Appendix E – Page 5
10. FAIR HOUSING REQUIREMENTS
A. Nondiscrimination. The Landlord shall not, in the provision of services or in any other manner discriminate against any person on the grounds of age, race, color, creed, religion, sex, handicap, national origin, or familial status. The obligation of the Landlord to comply with Fair Housing Requirements insures to the benefit of the United States of America, the Department of Housing and Urban Development, and the Program Administrator, any of which shall be entitled to involve any of the remedies available by law to redress any breach or to compel compliance by the Landlord.
B. Cooperation in Quality Opportunity Compliance Reviews. The Landlord shall comply with the Program Administrator and with HUD in conducting compliance reviews and complaint investigations pursuant to all applicable civil rights statutes, Executive Orders and all related rules and regulations.
11. PROGRAM ADMINISTRATOR AND HUD ACCESS TO LANDLORD RECORDS A. The Landlord shall provide any information pertinent to this Lease which the Program Administrator or HUD may reasonably require.
B. The Landlord shall permit the Program Administrator or HUD, or any of their authorized representatives, to have access to the premises and, for the purposes of audit and examination, to have access to any books, documents, papers, and records of the Landlord to the extent necessary to determine compliance with this Lease Addendum.
12. RIGHTS OF PROGRAM ADMINISTRATOR IF LANDLORD BREACHES THE LEASE
ADDENDUM
A. Any of the following shall constitute a breach of the Lease Addendum:
1. If the Landlord has violated any obligation under this Lease Addendum; or
2. If the Landlord has demonstrated any intention to violate any obligation under this Lease Addendum; or
3. If the Landlord has committed any fraud or made any false statement in connection with the Lease Addendum, or has committed fraud or made any false statement in connection with any Federal housing assistance program.
B. The PHA's right and remedies under the Lease include recovery of overpayments, termination or reduction of payments, and termination of the Lease. If the Program Administrator determines that a breach has occurred, the Program Administrator may exercise any of its rights or remedies under the Lease Addendum. The Program Administrator shall notify the Landlord in writing of such determination, including a brief statement of the reasons for the determination. The notice by the PHA to the landlord may require the Landlord to take corrective action by a time prescribed in the notice.
Appendix E
HAP-F Tenant Based Rental Assistance (TBRA)
LEASE ADDENDUM
Appendix E – Page 6
C. Any remedies employed by the Program Administrator in accordance with this Lease Addendum shall be effective as provided in a written notice by the Program Administrator to the Landlord. The Program Administrator's exercise or non-exercise of any remedy shall not constitute a waiver of the right to exercise that or any other right or remedy at any time.
13. RELATION TO THIRD PARTIES
A. The Program Administrator does not assume any responsibility for, or liability to, any person injured as a result of the Landlord's action or failure to act in connection with the implementation of this Lease Addendum, or as a result of any other action or failure to act by the Landlord.
B. The Landlord is not the agent of the Program Administrator and this Lease Addendum does not create or affect any relationship between the Program Administrator and any lender to the Landlord, or any suppliers, employees, contractors or subcontractors used by the Landlord in connection with this Lease Addendum.
C. Nothing in this Lease Addendum shall be construed as creating any right of the Tenant or a third party (other than HUD) to enforce any provision of this Lease Addendum or to asses any claim against HUD, the Program Administrator or the Landlord under this Lease Addendum.
14. CONFLICT OF INTEREST PROVISIONS
A. No employee of the Program Administrator who formulates policy or influences decisions with respect to the Rental Assistance Program, and no public official or member of a governing body or state of local legislator who exercise his functions or responsibilities with respect to the program shall have any direct or indirect interest during this person's tenure , or for one year thereafter, in this Lease Addendum or in any proceeds or benefits arising from the Lease Addendum or to any benefits which may arise from it.
15. TRANSFER OF THE LEASE ADDENDUM
A. The Landlord shall not transfer or assign this Lease Addendum in any manner, without the prior written consent of the Program Administrator. The Program Administrator shall give its consent to a transfer or assignment if the transferee agrees in writing (in a form acceptable to the Program Administrator) to comply with all terms and conditions of this Lease Addendum.
16. ENTIRE AGREEMENT: INTERPRETATION
A. This Lease Addendum contains the entire agreement between the Landlord and the Program Administrator. No changes in this Lease Addendum shall be made except in writing signed by both the Landlord and the Program Administrator.
Appendix E
HAP-F Tenant Based Rental Assistance (TBRA)
LEASE ADDENDUM
Appendix E – Page 7
B. The Lease Addendum shall be interpreted and implemented in accordance with HUD requirements .
17. WARRANTY OF LEGAL CAPACITY AND CONDITION OF UNIT
A. The Landlord warrants the unit is in decent, safe, and sanitary condition as defined in 24 CFR Section 882.109, and that the Landlord has the legal right to lease the dwelling unit covered by this Lease Addendum during the Lease Addendum term.
B. The individual executing this Lease Addendum on behalf of the Landlord hereby warrants that authorization has been given by the Landlord to execute it on behalf of the Landlord.
Landlord Name (Type or Print): Tenant (Type or Print):
(Signature/Date) (Signature/Date)
WARNING: 18 U.S.C. 1001 provides, among other things, that whoever knowingly and willingly makes or uses a document or writing containing any false, fictitious, or fraudulent statements or entries, in any matter within the jurisdiction of any department or agency of the United States, shall be fined not more than $10,000, or imprisoned for not more than five years, or both.
Signature of Tenant Date
Signature of Tenant Date
Signature of Tenant Date
Signature of Tenant Date
Appendix E
HAP-F Tenant Based Rental Assistance (TBRA)
LEASE ADDENDUM
Appendix E – Page 8
Signature of Landlord Date
Reasonable accommodations will be made for persons with disabilities and language assistance will be made available for persons with limited English proficiency.
VIOLENCE, DATING VIOLENCE U.S. Department of Housing OMB Approval No. 2502-0204 OR STALKING and Urban Development Exp. 6/30/2017 Office of Housing
Form HUD-91067
(9/2008)
LEASE ADDENDUM
VIOLENCE AGAINST WOMEN AND JUSTICE DEPARTMENT REAUTHORIZATION ACT OF 2005
TENANT
LANDLORD UNIT NO. & ADDRESS
This lease addendum adds the following paragraphs to the Lease between the above referenced Tenant and Landlord.
Purpose of the Addendum
The lease for the above referenced unit is being amended to include the provisions of the Violence Against Women and Justice Department Reauthorization Act of 2005 (VAWA).
Conflicts with Other Provisions of the Lease
In case of any conflict between the provisions of this Addendum and other sections of the Lease, the provisions of this Addendum shall prevail.
Term of the Lease Addendum
The effective date of this Lease Addendum is ______________. This Lease Addendum shall continue to be in effect until the Lease is terminated.
VAWA Protections
1. The Landlord may not consider incidents of domestic violence, dating violence or stalking as serious or repeated violations of the lease or other “good cause” for termination of assistance, tenancy or occupancy rights of the victim of abuse.
2. The Landlord may not consider criminal activity directly relating to abuse, engaged in by a member of a tenant’s household or any guest or other person under the tenant’s control, cause for termination of assistance, tenancy, or occupancy rights if the tenant or an immediate member of the tenant’s family is the victim or threatened victim of that abuse.
3. The Landlord may request in writing that the victim, or a family member on the victim’s behalf, certify that the individual is a victim of abuse and that the Certification of Domestic Violence, Dating Violence or Stalking, Form HUD-91066, or other documentation as noted on the certification form, be completed and submitted within 14 business days, or an agreed upon extension date, to receive protection under the VAWA. Failure to provide the certification or other supporting documentation within the specified timeframe may result in eviction.
_________________________________________ __________________ Tenant Date
_________________________________________ __________________ Landlord Date
Appendix F
APPENDIX F
IRS FORM W-9
[Behind this page.]
Form W-9
(Rev. October 2018)
Department of the Treasury
Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
a Go to www.irs.gov/FormW9 for instructions and the latest information.
Give Form to the
requester. Do not
send to the IRS.
Print or type.
See Specific Instructions on page 3.
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. 2 Business name/disregarded entity name, if different from above 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes.
Individual/sole proprietor or
single-member LLC
C Corporation S Corporation Partnership Trust/estate
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) a Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner.
Other (see instructions) a
4 Exemptions (codes apply only to
certain entities, not individuals; see
instructions on page 3):
Exempt payee code (if any)
Exemption from FATCA reporting
code (if any)
(Applies to accounts maintained outside the U.S.)
5 Address (number, street, and apt. or suite no.) See instructions. 6 City, state, and ZIP code
Requester’s name and address (optional)
7 List account number(s) here (optional)
Part I Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later.
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter.
Social security number
––
or
Employer identification number
–
Part II Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.
Sign
Here
Signature of
U.S. person a Date a
General Instructions
Section references are to the Internal Revenue Code unless otherwise noted.
Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Form 1099-INT (interest earned or paid)
• Form 1099-DIV (dividends, including those from stocks or mutual funds)
• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)
• Form 1099-B (stock or mutual fund sales and certain other transactions by brokers)
• Form 1099-S (proceeds from real estate transactions)
• Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition)
• Form 1099-C (canceled debt)
• Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN.
If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later.
Cat. No. 10231X Form W-9 (Rev. 10-2018)
Form W-9 (Rev. 10-2018) Page 2
By signing the filled-out form, you:
1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and
4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting, later, for further information.
Note: If you are a U.S. person and a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9.
Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are:
• An individual who is a U.S. citizen or U.S. resident alien; • A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States; • An estate (other than a foreign estate); or
• A domestic trust (as defined in Regulations section 301.7701-7).
Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section 1446 on any foreign partners’ share of effectively connected taxable income from such business. Further, in certain cases where a Form W-9 has not been received, the rules under section 1446 require a partnership to presume that a partner is a foreign person, and pay the section 1446 withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid section 1446 withholding on your share of partnership income.
In the cases below, the following person must give Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States.
• In the case of a disregarded entity with a U.S. owner, the U.S. owner of the disregarded entity and not the entity;
• In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally, the U.S. grantor or other U.S. owner of the grantor trust and not the trust; and
• In the case of a U.S. trust (other than a grantor trust), the U.S. trust (other than a grantor trust) and not the beneficiaries of the trust.
Foreign person. If you are a foreign person or the U.S. branch of a foreign bank that has elected to be treated as a U.S. person, do not use Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign Entities).
Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a “saving clause.” Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes.
If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W-9 that specifies the following five items.
1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien.
2. The treaty article addressing the income.
3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions.
4. The type and amount of income that qualifies for the exemption from tax.
5. Sufficient facts to justify the exemption from tax under the terms of the treaty article.
Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption.
If you are a nonresident alien or a foreign entity, give the requester the appropriate completed Form W-8 or Form 8233.
Backup Withholding
What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 24% of such payments. This is called “backup withholding.” Payments that may be subject to backup withholding include interest, tax-exempt interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, payments made in settlement of payment card and third party network transactions, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding.
You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return.
Payments you receive will be subject to backup withholding if:
1. You do not furnish your TIN to the requester,
2. You do not certify your TIN when required (see the instructions for Part II for details),
3. The IRS tells the requester that you furnished an incorrect TIN,
4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or
5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only).
Certain payees and payments are exempt from backup withholding.
See Exempt payee code, later, and the separate Instructions for the Requester of Form W-9 for more information.
Also see Special rules for partnerships, earlier.
What is FATCA Reporting?
The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign financial institution to report all United States account holders that are specified United States persons. Certain payees are exempt from FATCA reporting. See Exemption from FATCA reporting code, later, and the Instructions for the Requester of Form W-9 for more information.
Updating Your Information
You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account; for example, if the grantor of a grantor trust dies.
Penalties
Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect.
Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty.
Form W-9 (Rev. 10-2018) Page 3
Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment.
Misuse of TINs. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties.
Specific Instructions
Line 1
You must enter one of the following on this line; do not leave this line blank. The name should match the name on your tax return.
If this Form W-9 is for a joint account (other than an account maintained by a foreign financial institution (FFI)), list first, and then circle, the name of the person or entity whose number you entered in Part I of Form W-9. If you are providing Form W-9 to an FFI to document a joint account, each holder of the account that is a U.S. person must provide a Form W-9.
a. Individual. Generally, enter the name shown on your tax return. If you have changed your last name without informing the Social Security Administration (SSA) of the name change, enter your first name, the last name as shown on your social security card, and your new last name.
Note: ITIN applicant: Enter your individual name as it was entered on your Form W-7 application, line 1a. This should also be the same as the name you entered on the Form 1040/1040A/1040EZ you filed with your application.
b. Sole proprietor or single-member LLC. Enter your individual name as shown on your 1040/1040A/1040EZ on line 1. You may enter your business, trade, or “doing business as” (DBA) name on line 2. c. Partnership, LLC that is not a single-member LLC, C corporation, or S corporation. Enter the entity's name as shown on the entity's tax return on line 1 and any business, trade, or DBA name on line 2.
d. Other entities. Enter your name as shown on required U.S. federal tax documents on line 1. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on line 2.
e. Disregarded entity. For U.S. federal tax purposes, an entity that is disregarded as an entity separate from its owner is treated as a “disregarded entity.” See Regulations section 301.7701-2(c)(2)(iii). Enter the owner's name on line 1. The name of the entity entered on line 1 should never be a disregarded entity. The name on line 1 should be the name shown on the income tax return on which the income should be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a single owner that is a U.S. person, the U.S. owner's name is required to be provided on line 1. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity's name on line 2, “Business name/disregarded entity name.” If the owner of the disregarded entity is a foreign person, the owner must complete an appropriate Form W-8 instead of a Form W-9.
This is the case even if the foreign person has a U.S. TIN.
Line 2
If you have a business name, trade name, DBA name, or disregarded entity name, you may enter it on line 2.
Line 3
Check the appropriate box on line 3 for the U.S. federal tax classification of the person whose name is entered on line 1. Check only one box on line 3.
IF the entity/person on line 1 is
a(n) . . .
THEN check the box for . . .
• Corporation Corporation
• Individual
• Sole proprietorship, or
• Single-member limited liability
company (LLC) owned by an
individual and disregarded for U.S.
federal tax purposes.
Individual/sole proprietor or single-
member LLC
• LLC treated as a partnership for
U.S. federal tax purposes,
• LLC that has filed Form 8832 or
2553 to be taxed as a corporation,
or
• LLC that is disregarded as an
entity separate from its owner but
the owner is another LLC that is
not disregarded for U.S. federal tax
purposes.
Limited liability company and enter
the appropriate tax classification.
(P= Partnership; C= C corporation;
or S= S corporation)
• Partnership Partnership
• Trust/estate Trust/estate
Line 4, Exemptions
If you are exempt from backup withholding and/or FATCA reporting, enter in the appropriate space on line 4 any code(s) that may apply to you.
Exempt payee code.
• Generally, individuals (including sole proprietors) are not exempt from backup withholding.
• Except as provided below, corporations are exempt from backup withholding for certain payments, including interest and dividends. • Corporations are not exempt from backup withholding for payments made in settlement of payment card or third party network transactions. • Corporations are not exempt from backup withholding with respect to attorneys’ fees or gross proceeds paid to attorneys, and corporations that provide medical or health care services are not exempt with respect to payments reportable on Form 1099-MISC.
The following codes identify payees that are exempt from backup withholding. Enter the appropriate code in the space in line 4. 1—An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(f)(2)
2—The United States or any of its agencies or instrumentalities 3—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities 4—A foreign government or any of its political subdivisions, agencies, or instrumentalities
5—A corporation
6—A dealer in securities or commodities required to register in the United States, the District of Columbia, or a U.S. commonwealth or possession
7—A futures commission merchant registered with the Commodity Futures Trading Commission
8—A real estate investment trust
9—An entity registered at all times during the tax year under the Investment Company Act of 1940
10—A common trust fund operated by a bank under section 584(a) 11—A financial institution
12—A middleman known in the investment community as a nominee or custodian
13—A trust exempt from tax under section 664 or described in section 4947
Form W-9 (Rev. 10-2018) Page 4
The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 13.
IF the payment is for . . . THEN the payment is exempt
for . . .
Interest and dividend payments All exempt payees except for 7
Broker transactions Exempt payees 1 through 4 and 6
through 11 and all C corporations.
S corporations must not enter an
exempt payee code because they
are exempt only for sales of
noncovered securities acquired
prior to 2012.
Barter exchange transactions and
patronage dividends
Exempt payees 1 through 4
Payments over $600 required to be
reported and direct sales over
$5,000
1 Generally, exempt payees
1 through 52
Payments made in settlement of
payment card or third party network
transactions
Exempt payees 1 through 4
1 See Form 1099-MISC, Miscellaneous Income, and its instructions. 2 However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care payments, attorneys’ fees, gross proceeds paid to an attorney reportable under section 6045(f), and payments for services paid by a federal executive agency.
Exemption from FATCA reporting code. The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting this form for accounts maintained outside of the United States by certain foreign financial institutions. Therefore, if you are only submitting this form for an account you hold in the United States, you may leave this field blank. Consult with the person requesting this form if you are uncertain if the financial institution is subject to these requirements. A requester may indicate that a code is not required by providing you with a Form W-9 with “Not Applicable” (or any similar indication) written or printed on the line for a FATCA exemption code.
A—An organization exempt from tax under section 501(a) or any individual retirement plan as defined in section 7701(a)(37) B—The United States or any of its agencies or instrumentalities C—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities D—A corporation the stock of which is regularly traded on one or more established securities markets, as described in Regulations section 1.1472-1(c)(1)(i)
E—A corporation that is a member of the same expanded affiliated group as a corporation described in Regulations section 1.1472-1(c)(1)(i) F—A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is registered as such under the laws of the United States or any state
G—A real estate investment trust
H—A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of 1940
I—A common trust fund as defined in section 584(a)
J—A bank as defined in section 581
K—A broker
L—A trust exempt from tax under section 664 or described in section 4947(a)(1)
M—A tax exempt trust under a section 403(b) plan or section 457(g) plan
Note: You may wish to consult with the financial institution requesting this form to determine whether the FATCA code and/or exempt payee code should be completed.
Line 5
Enter your address (number, street, and apartment or suite number).
This is where the requester of this Form W-9 will mail your information returns. If this address differs from the one the requester already has on file, write NEW at the top. If a new address is provided, there is still a chance the old address will be used until the payor changes your address in their records.
Line 6
Enter your city, state, and ZIP code.
Part I. Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below.
If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN.
If you are a single-member LLC that is disregarded as an entity separate from its owner, enter the owner’s SSN (or EIN, if the owner has one). Do not enter the disregarded entity’s EIN. If the LLC is classified as a corporation or partnership, enter the entity’s EIN.
Note: See What Name and Number To Give the Requester, later, for further clarification of name and TIN combinations.
How to get a TIN. If you do not have a TIN, apply for one immediately.
To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local SSA office or get this form online at www.SSA.gov. You may also get this form by calling 1-800-772-1213.
Use Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS website at www.irs.gov/Businesses and clicking on Employer Identification Number (EIN) under Starting a Business. Go to www.irs.gov/Forms to view, download, or print Form W-7 and/or Form SS-4. Or, you can go to www.irs.gov/OrderForms to place an order and have Form W-7 and/or SS-4 mailed to you within 10 business days.
If you are asked to complete Form W-9 but do not have a TIN, apply for a TIN and write “Applied For” in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60-day rule does not apply to other types of payments.
You will be subject to backup withholding on all such payments until you provide your TIN to the requester.
Note: Entering “Applied For” means that you have already applied for a TIN or that you intend to apply for one soon.
Caution: A disregarded U.S. entity that has a foreign owner must use the appropriate Form W-8.
Part II. Certification
To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even if item 1, 4, or 5 below indicates otherwise.
For a joint account, only the person whose TIN is shown in Part I should sign (when required). In the case of a disregarded entity, the person identified on line 1 must sign. Exempt payees, see Exempt payee code, earlier.
Signature requirements. Complete the certification as indicated in items 1 through 5 below.
Form W-9 (Rev. 10-2018) Page 5
1. Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983.
You must give your correct TIN, but you do not have to sign the certification.
2. Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983. You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form.
3. Real estate transactions. You must sign the certification. You may cross out item 2 of the certification.
4. Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. “Other payments” include payments made in the course of the requester’s trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services, payments made in settlement of payment card and third party network transactions, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations).
5. Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), ABLE accounts (under section 529A), IRA, Coverdell ESA, Archer MSA or HSA contributions or
distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification.
What Name and Number To Give the Requester
For this type of account: Give name and SSN of:
1. Individual The individual
2. Two or more individuals (joint
account) other than an account
maintained by an FFI
The actual owner of the account or, if
combined funds, the first individual on
the account1
3. Two or more U.S. persons
(joint account maintained by an FFI)
Each holder of the account
4. Custodial account of a minor
(Uniform Gift to Minors Act)
The minor2
5. a. The usual revocable savings trust
(grantor is also trustee)
b. So-called trust account that is not
a legal or valid trust under state law
The grantor-trustee1
The actual owner
1 6. Sole proprietorship or disregarded
entity owned by an individual
The owner
3 7. Grantor trust filing under Optional
Form 1099 Filing Method 1 (see
Regulations section 1.671-4(b)(2)(i)
(A))
The grantor*
For this type of account: Give name and EIN of:
8. Disregarded entity not owned by an
individual
The owner
9. A valid trust, estate, or pension trust Legal entity4
10. Corporation or LLC electing
corporate status on Form 8832 or
Form 2553
The corporation
11. Association, club, religious,
charitable, educational, or other tax-
exempt organization
The organization
12. Partnership or multi-member LLC The partnership
13. A broker or registered nominee The broker or nominee For this type of account: Give name and EIN of:
14. Account with the Department of
Agriculture in the name of a public
entity (such as a state or local
government, school district, or
prison) that receives agricultural
program payments
The public entity
15. Grantor trust filing under the Form
1041 Filing Method or the Optional
Form 1099 Filing Method 2 (see
Regulations section 1.671-4(b)(2)(i)(B))
The trust
1 List first and circle the name of the person whose number you furnish.
If only one person on a joint account has an SSN, that person’s number must be furnished.
2 Circle the minor’s name and furnish the minor’s SSN.
3 You must show your individual name and you may also enter your business or DBA name on the “Business name/disregarded entity” name line. You may use either your SSN or EIN (if you have one), but the IRS encourages you to use your SSN.
4 List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) Also see Special rules for partnerships, earlier.
*Note: The grantor also must provide a Form W-9 to trustee of trust.
Note: If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed.
Secure Your Tax Records From Identity Theft
Identity theft occurs when someone uses your personal information such as your name, SSN, or other identifying information, without your permission, to commit fraud or other crimes. An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund.
To reduce your risk:
• Protect your SSN,
• Ensure your employer is protecting your SSN, and
• Be careful when choosing a tax preparer.
If your tax records are affected by identity theft and you receive a notice from the IRS, respond right away to the name and phone number printed on the IRS notice or letter.
If your tax records are not currently affected by identity theft but you think you are at risk due to a lost or stolen purse or wallet, questionable credit card activity or credit report, contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit Form 14039.
For more information, see Pub. 5027, Identity Theft Information for Taxpayers.
Victims of identity theft who are experiencing economic harm or a systemic problem, or are seeking help in resolving tax problems that have not been resolved through normal channels, may be eligible for Taxpayer Advocate Service (TAS) assistance. You can reach TAS by calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD 1-800-829-4059.
Protect yourself from suspicious emails or phishing schemes.
Phishing is the creation and use of email and websites designed to mimic legitimate business emails and websites. The most common act is sending an email to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user into surrendering private information that will be used for identity theft.
Form W-9 (Rev. 10-2018) Page 6
The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers, passwords, or similar secret access information for their credit card, bank, or other financial accounts.
If you receive an unsolicited email claiming to be from the IRS, forward this message to [email protected]. You may also report misuse of the IRS name, logo, or other IRS property to the Treasury Inspector General for Tax Administration (TIGTA) at 1-800-366-4484. You can forward suspicious emails to the Federal Trade Commission at [email protected] or report them at www.ftc.gov/complaint. You can contact the FTC at www.ftc.gov/idtheft or 877-IDTHEFT (877-438-4338).
If you have been the victim of identity theft, see www.IdentityTheft.gov and Pub. 5027.
Visit www.irs.gov/IdentityTheft to learn more about identity theft and how to reduce your risk.
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information.
Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer.
Certain penalties may also apply for providing false or fraudulent information.
Appendix G
APPENDIX G
ANAHEIM HOUSING AUTHORITY PROCEDURAL MEMORANDUM AND PAYMENT
STANDARDS
[Behind this page.]
2022-2023 PAYMENT STANDARDS FOR AREA-WIDE PHAS
BR
Size
FMR
10/01/22
AHA
EFF 10/01/22
SAHA
EFF 10/01/22
GGHA
EFF 10/01/22
OCHA
EFF 10/01/22
All of
Anaheim Regular EHVs
Only
All of
Garden Grove
Basic
(1)
Central
(2)
Restricted
(3)
EHVs
Only
SRO 1,454 1599 1526 1672 N/A 1454 1454 1454 1673
0 1939 2133 2035 2230 1939 1939 2035 2132 2230
1 2113 2325 2219 2430 2113 2113 2219 2324 2430
2 2539 2793 2665 2920 2539 2539 2665 2792 2920
3 3448 3793 3620 3965 3448 3448 3620 3792 3965
4 4032 4436 4234 4637 4032 4032 4234 4435 4637
5 4637 5101 4869 5332 4637 4637 4869 5100 5333
6 5242 5767 5504 6028 N/A 5242 5504 5766 6028
AHA
Anaheim HA's new payment standards are effective 10/1/2022, and are set at 110% of the Fair Market Rents (FMR) for all bedroom sizes.
GGHA
Garden Grove HA's new payment standards are effective 10/1/2022 for new leases and 12/1/2022 for annuals, and are set at 100% of the FMR.
OCHA
Orange County HA's new payment standards are effective 10/1/2022 (1) Basic PS: Brea, Buena Park, Cypress, Fullerton, Laguna Woods, La Habra, La Palma, Los Alamitos, Orange, Placentia, Seal Beach, Stanton, Villa Park, Westminster, Yorba Linda, and unincorporated areas (e.g. Midway City) north of the 55 freeway. (2) Central PS: The following "central coast" cities within the county qualify for Central Payments Standards: Costa Mesa, Fountain Valley, and Huntington Beach. (3) Restricted PS: The following "high rent areas" of the county qualify for Restricted Payments Standards: Aliso Viejo, Dana Point, Irvine, Laguna Beach, Laguna Hills, Laguna Niguel, Lake Forest, Mission Viejo, Newport Beach, Rancho Santa Margarita, San Juan Capistrano (including Capistrano Bea ch), San Clemente, Tustin, and unincorporated areas south of the 55 freeway.
SAHA
Santa Ana HA's new payment standards are effective 10/1/2022 and set at 105% of the FMR for all bedroom sizes.
Revised 10/14/2022
Appendix G
Appendix H
APPENDIX H
AHA UTILITY ALLOWANCE SCHEDULE
[Behind this page.]
01234 5 +
233456
15 18 20 23 28 35
7 8 9 1 01 31 6
5 6 12 12 16 19
113344
7 8 16 16 21 25
4 4 8 8 11 13
TOTA
L
*Based on HUD % Breakdown
Heating
Water Heating
Water 25 45
Trash/ Sewer/Street 35
Refrigerator (Tenant-supplied) 13
Stove (Tenant-supplied) 11
Cooking
ANAHEIM HOUSING AUTHORITY
UTILITY ALLOWANCE SCHEDULE
SECTION 8 ASSISTED HOUSING
EFFECTIVE DATE: November 1, 2022
BEDROOM SIZE
Gas
Cooking
Heating
Water Heating
Electric
Basic
ENERGY-EFFICIENT
01234 5 +
44568 1 0
23 28 32 37 48 62
10 12 14 17 22 28
8 9 15 25 27 31
223667
10 12 19 33 36 41
5 6 10 17 18 21
TOTA
L
*Based on HUD % Breakdown
Trash/ Sewer/Street 35
Refrigerator (Tenant-supplied) 13
Stove (Tenant-supplied) 11
Water Heating
Water 55 83
Heating
SECTION 8 ASSISTED HOUSING
"Regular," non-energy efficient units
EFFECTIVE DATE: November 1, 2022
BEDROOM SIZE
Gas
Cooking
Heating
Water Heating
Electric
Basic
Cooking
UTILITY ALLOWANCE SCHEDULE
ANAHEIM HOUSING AUTHORITY
Appendix I
APPENDIX I
CLIENT OUTCOME MATRIX FORM
[Behind this page.]
Appendix I
Client Outcome Matrix
Page | 1
Domains In Crisis
Score: 1
Vulnerable
Score: 2
Safe
Score: 3
Building Capacity
Score: 4
Empowered
Score: 5
Income
Score____
Score____
Score____
No source of income
Inadequate income
and/or spontaneous or
inappropriate spending
Can meet basic needs
with a subsidy;
appropriate spending
Can meet basic needs
and manage debt
without assistance
Income is sufficient,
and well managed;
has discretionary
income and can save
Employment
Score____
Score____
Score____
Unemployed/not
seeking employment
Temporary, part-time,
or seasonal;
inadequate pay; no
benefits
Employed full time;
inadequate pay; few or
no benefits
Employed full-time with
adequate pay and
benefits
Maintains permanent
employment with
adequate income and
benefits
Shelter
Score____
Score____
Score____
Homeless or
threatened with
eviction
In transitional,
temporary, or
substandard housing;
and/or current
rent/mortgage payment
is
unaffordable
In stable housing that
is safe but only
marginally adequate
Household is safe,
adequate, subsidized
housing
Household is safe,
adequate,
unsubsidized housing
Food
Score____
Score______
Score____
No food or means to
prepare it. Relies to a
significant degree on
other sources of free or
low-cost
The household is on
food stamps
Can meet basic needs
but requires occasional
assistance
Can meet basic needs
without assistance
Can choose to
purchase any food
household desires
Childcare
Score____
Score____
Score____
Needs childcare but
none is available/
accessible and/or the
child is not eligible
Childcare is unreliable
or unaffordable;
inadequate supervision
is a problem for
childcare that is
available
Affordable subsidized
childcare is available
but limited
Reliable, affordable
childcare is available;
no need for subsidies
Able to select quality
childcare of choice
Children’s
education
Score____
Score____
score____
One or more eligible
children not enrolled in
school
One or more eligible
children enrolled in
school but not
attending classes
Enrolled in school, but
one or more children
only occasionally
attend classes
Enrolled in school and
attending classes most
of the time
All eligible children
enrolled and
attending regularly
Adult Education
Score____
Score____
Score____
Literacy problems
and/or no high school
diploma/GED are
serious barriers to
employment
Enrolled in literacy
and/or GED program
and/or has sufficient
command of English
so language is not a
barrier to employment
Has a high school
diploma/GED
Need additional
education/training to
improve employment
situation and/or to
resolve literacy
problems to where
they can function
effectively in society
Has completed
education/training
needed to become
employable. No
literacy problems
Legal
Score____
Score____
Score_____
Current outstanding
tickets or warrants
Current charges/trial
pending;
noncompliance with
probation/parole
Fully compliant with
probation/parole terms
Has completed
probation/parole within
the past 12 months; no
new charges filed
No felony criminal
history and/or no
active criminal justice
involvement in more
than 12 months
Health Care
Score____
Score____
Score____
No medical coverage
with an immediate
need
No medical coverage
and great difficulty
accessing medical
care when needed.
Some household
members may be in
poor health
Some members
All members can get
medical care when
needed but may strain
the budget
All members are
covered by
affordable, adequate
health insurance
Basic Needs
Score____
Score____
Score____
Unable to meet basic
needs such as
hygiene, food,
activities of daily living
Can meet a few but not
all needs of daily living
without assistance
Can meet most but not
all daily living needs
without assistance
Able to meet all basic
needs of daily living
without assistance
Able to provide
beyond basic needs
of daily living for self
and family
Appendix I
Client Outcome Matrix
Page | 2
Domains In Crisis
Score: 1
Vulnerable
Score: 2
Safe
Score: 3
Building Capacity
Score: 4
Empowered
Score: 5
Mental Health
Score____
Score____
Score____
Danger to self or
others; recurring
suicidal ideation;
experiencing severe
difficulty in day-to-day
life due to
psychological
problems
Recurrent mental
health symptoms that
may affect behavior
but not a danger to
self/others; persistent
problems with
functioning due to
mental health
symptoms
Mild symptoms may be
present but are
transient; only
moderate difficulty in
functioning due to
mental health
problems
Minimal symptoms that
are acceptable
responses to life
stressors; only slight
impairment in
functioning
Symptoms are absent
or rare; good or
superior functioning in
a wide range of
activities; no more
than everyday
problems/concerns
Substance
Score____
Score____
Abuse______
Meets criteria for
severe abuse; resulting
in problems so severe
that institutional living
or hospitalization may
be necessary
Meets criteria for
dependence;
preoccupation with use
and/or obtaining
drugs/alcohol;
withdrawal or
withdrawal avoidance
behaviors evident; use
results in avoidance or
neglect of essential life
activities
Use within last 6
months; evidence of
persistent or recurrent
social, occupational,
emotional, or physical
problems related to
use; problems that
have persisted for at
least one month
The client has used
during the last 6
months but has no
evidence of persistent
or recurrent social,
occupational,
emotional, or physical
problems related to
use; no evidence of
recurrent dangerous
No drug use/alcohol
abuse in the last 6
months
Family Relations
Score____
Score____
Score____
Lack of necessary
support from family or
friends; abuse (DV,
child) is present or
there is child neglect
Family/friends may be
supportive but lack the
ability or resources to
help; family members
do not relate well with
one another
Some support from
family/friends; family
members acknowledge
and seek to change
negative behaviors;
are learning to
communicate and
support
Strong support from
family or friends;
household members
support each other’s
efforts
Has a
healthy/expanding
support network; the
household is stable
and communication is
consistently open
Transportation/
Mobility
Score____
Score____
Score____
No access to
transportation, public
or private; may have
an inoperable car
Transportation is
available but
unreliable,
unpredictable, and
unaffordable; one may
have a car but no
insurance, license, etc
Transportation is
available and reliable
but limited and/or
inconvenient; drivers
are licensed and
minimally insured
Transportation is
generally accessible to
meet basic travel
needs
Transportation is
readily available and
affordable; the car is
adequately insured
Socialization
Score____
Score____
Score____
Social Isolation
Limited social
connections/
interactions
Few social interactions
limited access to
healthy social outlets
Multiple healthy social
connections
Social
Connection/Engagem
ent with Community
Access to benefits
Score____
Score____
Score____
Not aware benefits are
available or not
receiving benefits
Has applied for
benefits and is
awaiting results
Has received some
benefits, but still
requires others to meet
the level of need
Has received benefits
sufficient to meet the
level of need
Does not require
benefits
Parenting skills
Score____
Score____
Score____
There are safety
concerns regarding
parenting skills
Parenting skills are
minimal
Parenting skills are
apparent but not
adequate
Parenting skills are
adequate
Parenting skills are
well developed
Appendix I
Client Outcome Matrix
Page | 3
Ho
usehold: ________________________
Inta
ke Date: ________________________ CM Completing Matrix: ________________________ 12 Mo
nths: ________________________ CM Completing Matrix: ________________________ Ex
it Date: ________________________ CM Completing Matrix: ________________________ Entry 12 months Exit
Income
Employment
Shelter
Food
Childcare
Children’s Education
Adult Education
Legal
Health Care
Basic Needs
Mental Health
Substance Abuse
Family Relations
Transportation/Mobility
Social/Community Involvement
Access to Benefits
Parenting Skills
TOTAL
LEVEL OF STABILITY
(See the Below Chart)
In Crisis = 33 or below
Vulnerable = 34-50
Safe = 51-67
Building Capacity = 68-80
Empowered = 81 or above
Households that score between 0 - 80 on the client outcome matrix will be eligible for a subsidy extension. Extensions beyond the first 12 months will be granted at the discretion of the City HAP-F program manager and shall require written approval which will be based on continued program compliance and ongoing need. Written approval must be requested beyond the 12th month of rental assistance and obtained before reaching the 15th 18th, 21st, and/or 24th month term
Appendix J
APPENDIX J
CASE MANAGEMENT AND SELF SUFFICIENCY PROGRAM POLICIES AND
PROCEDURES
[Behind this page.]
P a g e 1 | 12
Appendix J
HAP-F
Self – sufficiency Program
POLICIES AND PROCEDURES
PRE-INTAKE PROCEDURES
• Prospective applicants to the Homeless Assistance Program for Families (HAP-F) may contact Service Provider by:
o Receiving a referral from their children's Anaheim School McKinney Vento Liaison (MVL). Prior to referring a family to HAP-F, MVL will assess the family for a history of residency in the City of Anaheim and children's enrollment in an Anaheim School
• Applicants are qualified for the program if they:
o Have minor-aged children under 18 or are at least 7 months pregnant. o Have valid photo identification or are in the process of acquiring photo identification. o Have a residency history in the City of Anaheim.
• Applicants are ineligible for the program if they:
o Are a registered sex offender.
o Have a record of violent crimes, sex crimes, or crimes against a child. (Adults with a criminal history will be reviewed on a case-by-case basis and can be considered for the program. depending upon the nature of the offense and date that the offense occurred.)
o Have a total household income that falls above the extremely low-income limit Published by HUD adjusted family size.
• The Pre-intake Diversion Interest Form may be found online or on-site . Completed applications may be submitted to Service Provider
• The application will include MVL release of information referral form and attendance and grades for all children in family unit.
• The Program Coordinator will receive appropriate referrals from Anaheim MVLs. All referrals and contact with referred families. in person or by phone, must be logged in the HAPP Referral Log Google Doc . • The Manager of Program Operations will assign referred families to a Case Manager, which will be reflected on the HAP-F Referral Log.
• All other Site/Program Coordinator and Case Manager interactions, in person or by phone, must be logged In the HAPP Referral Log until referred families have completed their intake paperwork for enrollment. • As funding and space are available, referred families who are deemed a fit for the program may be moved in immediately or will be waitlisted. The Manager of Program Operations will notify the Site Coordinator of families approved for move-in or for the waitlist.
• Waitlisted applicants will be added to the program based upon need and site availability. • Program Coordinators and assigned Case Managers at the Anaheim site will receive assigned referrals and referred families to schedule an initial intake appointment.
• The Site Coordinator and the Program Coordinator will coordinate bridge housing (paid through Anaheim ESG Funds) either in Illumination residential homes, to ensure that referred families have a stable place to reside while the family, in partnership with their Case Manager and Housing Navigator, secure a lease. • The Site Coordinator will conduct a background check on all adults via the OCCourts.org
P a g e 2 |
INTAKE Procedure
o Upon IF receiving an appropriate referral. the new family will participate in program intake, during which the Site Coordinator and Case Manager will:
o Review all intake paperwork (Welcome Letter. If Guidelines. Photo Release, CMIS Consent and Intake. 0-5 Consent and Intake when applicable). which must be signed and dated by the adult(s). o Provide copies of all signed paperwork.
o Explain program participation expectations.
o Schedule an appointment for the family to meet with their Case Manager for their first case management meeting to develop a Housing Plan within the week. o Inform the family of their first Resource Group Meeting, Behavioral Health and Workforce assessments, and the New Family Orientation.
o Provide a calendar for the month and update the new family of any other important events or information.
o Notify the family that guidelines, job leads, resources. and other important information will be assessable on-site for future reference.
• The Program Coordinator will assign a case number for the new family. • Assigned Case Manager will update HMIS and the necessary Google Docs {Family Master, Family Contact Information) with families information.
• The Program Coordinator will create a case file for the new family with the Pre-Intake Application. signed intake paperwork, copies of photo ID's: the file will be clearly labeled with the case number and (mother's) last name. • The Program Coordinator will review the background check for any criminal cases and discuss any concerns with the Management Team.
• Upon completing the necessary paperwork during the program intake, the new family will begin a two week assessment period.
• During the first two weeks of enrollment. families will need to complete the following assessments:
o Case Management develop a Housing Plan in partnership with Case Manager, where proof of income and expenses will be provided, and complete a budget and determine the family's rent payment for the first month. o Behavioral Health with the Manager of Program Operations for recommendations for one or more of the following: individual, couples. family, or group therapy. o Workforce Development with the Job Coach to receive recommendations for participation in the Job Readiness Training or Job Readiness Training Ute programs. o Complete a referral form for an in-home medical visitation by a Public Health Nurses. • After the first two weeks and throughout enrollment, families will:
o Meet with the assigned Case Manager weekly.
o Be expected to complete goals mutually set during case management. o Be expected to attend at least 80% of activities.
o Pay their rent portion monthly.
PROGRAM PROCEDURES
• Apartment and Lease Allocation
o During the two-week assessment time, families will be encouraged by their Case Manager to begin searching for an appropriate apartment, following the two plus one rule for family size in relation to needed bedrooms.
P a g e 3 |
o lf families encounter difficulty in locating a cooperative apartment complex after their first two weeks in the program the Housing Developer will begin to work collaboratively with families and their Case Manager.
o Once an appropriate apartment is secured the Housing Developer will meet with the Property Manager or Landlord to review HAPP Policies and payment procedures and collect necessary documentation.
o After families sign their lease the Housing Developer will complete all needed inspections. o Upon completion of successful inspections Housing Developer will deliver certified move in funds and families will move into their secured apartment
• Rent
o Rent portions are set by the Manager upon families' completion of the two-week assessment period. Families will pay no less than 30% of their gross income towards rent. As families' incomes, increase their 30% income payment toward rent will be adjusted upward according to the family's budget until the family hos sufficient income to maintain apartment rent independently. The Associate Manager and Case Manager will provide the family with a Stipend Award Letter which will det il the incremental increase for the family's rent portion to be paid each month and the comparative incremental decrease of IF's subsidy each month. o If families' gross income Increases to above the 2019 HUD extremely-low income limit, the family's rent stipend will cease.
o The monthly rent stipends provided by IF are not guaranteed. If families disengaged in contact or communication with their Case Manager for three consecutive months and do no contribute to their rent portion, rental subsidies will be terminated.
• At the end of each month all families will be reviewed for goal progress and communication with their Case Manager. In the case of a family who has disengaged from Case_ Manager communication, the family will be placed on an intervention plan detailing barriers and mutually agreed upon intervention to address detailed barriers. If a family receives an intervention plan for three consecutive months subsidies will be terminated due to lack of engagement. o All families will develop a mutually agreed upon five month program exit plan. Families will work to increase gross household income in order to maintain independence at the end of the five-month subsidy term. o The family's rent will increase $100 every other month until the family is paying the full rent amount or until program exit. Famines will need to gain additional income in order to accommodate the monthly increase in rent.
o Families are eligible to request suspensions of their monthly incremental rent increases. It Is important that families plan and discuss their income and expenses with their Case Manager thoroughly, as rental subsidies are not long term. The $100 bi-monthly rental increases may be adjusted for families based on extenuating life circumstances, unplanned expenses, or unexpected loss of income. o Any issues or concerns regarding rent must be discussed with the family's Case Manager and brought to the Case Management Team Meeting one week prior to the end of the month. The Case Manager will discuss options with the Case Manager's Supervisor and/or Associate Manager, who will consult with the Director of Program Operations.
o Rent issues must be resolved at least one week before the rent deadline. o Any rent adjustments made will be approved by the Manager and entered into the Monthly Rent Due Google Doc.
P a g e 4 |
o By the first of each month. the Manager will notify all apartment properties of the rental amounts for families.
o Families are to pay their portion of rent in full directly to the Property Manager or Landlord at their apartment location within the time specified on their lease. o Families are to request and receive a rent receipt to document their rental payment. and provide a copy of their rental receipt to their Case Manager monthly. o The Housing Navigator will communicate with partnership properties monthly to insure families' rent portions are paid in full. The Housing Developer will notify the Associate Manager of which families have not paid their full rent amount. Families who have not paid their full rent will be reviewed by the Associate Manager and Case Manager for continuation or termination from the program. • Case Management Teams
o The Lead Case Manager will be responsible for designing client's overall care plan upon program entry, establishing mutually agreed -upon weekly, monthly and long -term goals and then making referral to appropriate Case Management Specialist based on core plan goals. Case Management Specialist are as follows:
• lead Case Manager: all specialists carry a caseload of clients acting as the lead case manager to coordinate the progression and needs of the case.
• Housing Retention Specialist: acts as a landlord/client liaison to sustain retention of housing and accompany clients in building life skills that will increase self-sufficiency and housing retention .
Role maintains substance use and CTI focus and provides case support by conducting harm reduction interventions for clients who are using substances. • Early Intervention Retention Specialist: accompany clients in building life skills that will lead to housing retention and assist in crisis intervention in emergency and bridge housing. • Mental Health Coordinator: provides therapy, mental health support. and resource connections to clients.
■ Housing Developer: building relationships with landlords and community outreach with the purpose of property acquisition and contract management. • Employment Specialist: prov i d e s case support by assisting clients in job development skills and making connections to employment.
• System Navigation Specialist: provides case support by assisting clients in accessing social service benefits and resources.
■ Medical Specialist: provides case support by helping clients navigate access to medical needs as well as maintain medical stability.
• Outreach Specialist: build relationships with community members and vulnerable families and individuals with the purpose of service and housing connection. • Peer Specialist: provides case support from the perspective of lived experience and past success in moving out of homelessness and into permanent housing. o Director of Housing Services and Manager of Housing Services meets with each team member on a monthly basis to review goal progress for lead cases as well as quality of care for all specialist cases. o For the first months in the program , new families are eligible for bus passes as well as diapers. wipes and other miscellaneous supplies to be provided by the Case Manager. o AU bus passes given to families must be stamped and returned to the Case Manage r to verify proper use and put into the family's file.
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■ Upon reaching the one-month mark, families may earn the rewards through the Voucher Hour Program (description below).
o The Lead Case Manager meets with families monthly to monitor mutually sets goals essential to progressing in the program.
o The Lead Case Manager completes Client Outcome Matrix paperwork upon entry, three months, six months. one year and exit.
o All school aged children must be enrolled and attending school regularly. Children 18 or older will be required to attend case management. The child's case management session may be with or separate from the parents' session, at the Case Manager's discretion.
o Families must provide proof of school-aged children's attendance monthly to their Lead Case Manager.
• Savings
o Families will be encouraged to save money by opening their own savings account and making monthly deposits. o Families should submit proof of depositing monthly into their savings account to their Case Manager. • Voucher Hour Program
o The community service Voucher Hour Program consists of families volunteering time in exchange for monetary rewards.
o Each hour volunteered is worth a $5 voucher redemption. o Families must share what they are working towards and receive permission from their Case Manager to complete voucher hours.
o The Site Coordinator will be responsible for assigning as well as logging voucher hours in the IF Hours Google Doc.
o Families must also keep track of their hours in paper on the Daily Log document. o Requests for voucher redemptions are to be sent by email from the Case Manager or Site Coordinator to the Associate Manager a minimum of one week prior to funds being needed. o The Associate Manager will supply the funds and the Case Manager or Site Coordinator will document the disbursement on the IF Hours Google Doc.
• Behavioral Health
o Behavioral health sessions may include individual therapy, couples therapy, family therapy, or Life Skills Groups. o The assigned Therapist will be responsible for scheduling the first appointment. o The family will also be given the phone number of the assigned Therapist by the Case Manager and will be responsible to follow up with the Therapist for scheduling an appointment. o If an individual wishes to be reassigned a Therapist, the Case Manager will inform the Manager of Program Operations, who will assess and conduct transfer of case. o Individuals receiving therapy services off-site may be excused from IF therapy sessions if a release of information is signed and attendance of off-site therapy can be verified. o If an individual or family has missed two appointments, the Therapist will notify the Case Manager, and the Case Manager will be responsible to follow up and remind the family of the therapy requirement. • Program Compliance
o Case Managers, Site Coordinators document monthly attendance in the Overall Monthly Attendance Google Doc by the end of the first week of the following month. o Families are encouraged to attend weekly Life Skills Group Meetings, New Family Orientation, case management.
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therapy appointments, workforce appointments, other groups/classes, and other mandatory events. Absences from scheduled Life Skills Group Meetings may be excused only if both adults are unable to attend due to work for school. Proof of work or school schedule must be submitted in order for absence to be excused. o At the end of each month all families will be reviewed for goal progress, engagement, and communication with their Case Manager. In the case of a family who has disengaged from Case Manager communication, the family will be placed on an intervention plan (Participation Agreement) detailing family barriers to stability and mutually agreed upon Interventions to address detailed barriers.
o The Participation Agreement will utilize progressive engagement strategies to develop client buy in and reinforce that with out participation and engagement in services Families will be unable to maintain their housing. o If the family is between 50% and 80% engagement the Manager of Program Operations and Case Manager will discuss if the family should be given a Participation Agreement. o Participation Agreement contracts are prepared, delivered to the family and administered by the Case Managers to discuss with the families.
o Upon a family's second Participation Agreement. the Case Manager and the Manager of Program Operations will prepare a new contract to address the family's situation and IF's specific expectations for the family. If the family fails to Improve after the second Participation Agreement, the family will risk being exited from the program.
o Should a third Participation Agreement be needed, the family will meet with the Manager of Program Operations and the Director of Program Operations. Families will be reviewed on a case-by-case basis for continuation or termination from the program.
o Families who have been placed on Participation Agreements for three consecutive months will be terminated from the subsidy program due to lack of engagement. • Drug Testing
o Adults may be drug tested randomly or based on suspicion. o Clients requiring a drug test will be determined by the Management Team and Case Managers during Case Management Team Meetings.
o The Site Coordinator will conduct the drug test. with a member of the Management Team present during testing.
o Site Coordinator, Associate Managers, and the Director of Program Operations will be Universal Precautions Certified in order to conduct drug tests safely. o Clients have the right to request a different staff person to conduct the drug test based on gender. Staff will do their best to accommodate the client's request in a timely manner. o Clients may not leave the office until the drug test has been conducted, otherwise the test will be considered Invalid and a refusal to comply.
o Refusal to comply with drug testing equates to a positive drug test. o Clients who test positive for illegal drugs will choose to either begin a treatment plan and comply with a Harm Reduction Program or exit the program.
• Harm Reduction Program
o All requirements must be met in order to complete the eight-week Harm Reduction Program. o Program requirements include:
■ A minimum of 4 (up to 6) drug tests.
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An additional weekly case management session (total of two case management sessions per week) for eight weeks. covering the following topics: self-assessment: timeline of life and use: education and consequences; stress coping and alternatives; triggers. boundaries and high risk situations; relapse prevention and lessons learned. ■ Completing at least one item from each category in a list of Level 1, Level 2, and Level 3 activities. o All Harm Reduction Program updates and completed requirements will be documented by the Case Manager In the Harm Reduction Program Google Doc.
o Case Management Team Meetings
o Case Management Team Meetings will toke place on Tuesday and Thursday every week: at the Multi Service Center.
o The meeting will cover any major concerns with families, potential exits, drug tests needed, harm reduction updates, participation agreement updates, rent issues, probation, client concerns. successes, and other general program issues and announcements.
o Case Managers must send client updates to the Manager of Program Operations 24 hours prior to the meeting.
o The Manager of Program Operations will create the meeting agenda. o Outside collaborators may participate In Case Management Team Meetings upon invitation and must sign the IF Confidentiality Agreement.
o Resource Group Meetings will take place weekly at the MSC .
CHILDREN AND FAMILIES COMMISSION REQUIREMENTS
• Data Tracking and Statistics
o The Case Manager is responsible for- creating goals in accordance with Children Family Commission requirements !developmental screenings, healthcare home, dental home, etc.). o The Case Manager must document these goals with goals sheets and on the Service and Referral Tracking Sheet in the file.
■ Monthly stats are to be submitted to the Operations Program Coordinator at the end of the first week of the following month on the 0 -5 CFC Google Doc. • Case Managers will add any new families to their monthly stats submitted to the 0-5 Coordinator, who will input new families into HMIS.
• Case Managers will highlight exited families in red on the 0 -5 CFC Google Doc, and the 0 -5 Coordinator will exit exited families from HMIS.
• The Associate Manager will Input the group/aggregate stats into HMIS. o The Associate Manager is responsible for tracking goals met in the 0 -5 CFC Stats Google Doc as well as in the HMIS Database.
EXITING PROCEDURES
• All families will develop a mutually agreed upon 12 to 18 month program exit plan. Families will work to increase gross household income in order to maintain independence at the end of 12 to 18 month2 from enrollment.
• Families reaching their one-year mark in the program will be exited from the program (if deemed stable) and considered a graduate. and they may continue to receive case management and other program services for up to six months.
• If the family falls to comply with program guidelines, the case will be reviewed by the Case Management Team and assessed for continuation or termination from the program. In the case that the Case Manager • and Management Team is unable to review the situation. the Case Manager, Associate Mana ge r, and Director
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of Housing Services may assess the family fo r continuation or termination • Should a partnership property choose to exit a family from the premises, they may risk exit from the program as well. o Should the family merit an exception, the Case Management Team will have the authority to transition the family to a different site.
• When a family exits, the Site Coordinator will notify the Management Team, PHN, partnership property, Case Manager, and Therapist.
• Exiting families will complete an exit interview with their Case Manager, during which the family will complete the CMIS and IF exit forms and the 0-5 exit forms If applicable. • The Case Manager must review the completed file and case notes with the Manager or Director of Housing Services.
Upon approval. the Case Manager will exit the family from HMIS. • The Case Manager will update the necessary Google Docs {Family Master, Family Contact). • Upon exit, a client will be assigned a Program Exit Status: Permanent housing. Motel on own, Transitional housing, Stayed with family/friends, Self-checkout, Motel vacated, Non-compliant, or Didn't meet requirements. • Graduate status may include any families in the following categories: Permanent housing, Remained In motel on own, Transitional housing, Stayed with family/friends.
• The Case Manager is responsible for acquiring a method of contact for the exiting families, in order to maintain a relationship with graduates.
Graduates will be tracked by their Case Manager at three months and six months after exiting the program.