S
S
A
A
M
M
P
P
L
L
E
E
C
C
L
L
I
I
E
E
N
N
T
T
F
F
I
I
L
L
E
E
C
C
O
O
N
N
T
T
E
E
N
N
T
T
S
S
C
C
H
H
E
E
C
C
K
K
L
L
I
I
S
S
T
T
H
H
O
O
U
U
S
S
I
I
N
N
G
G
O
O
P
P
P
P
O
O
R
R
T
T
U
U
N
N
I
I
T
T
I
I
E
E
S
S
F
F
O
O
R
R
P
P
E
E
R
R
S
S
O
O
N
N
S
S
W
W
I
I
T
T
H
H
A
A
I
I
D
D
S
S
Note: Not all forms apply to every HOPWA program
Client Name: (optional)
Client Code #:
Case Manager:
Completed Intake/Assessment form (including client data, i.e. contact info.,
demographics & information reported to funder)
Signed Authorization to Release and Obtain Information (ROI), Annually updated
HIV Verification (signed by certified health practitioner/testing site (only at intake):
Completed Household Income Verification: (Attach Income/Budget Worksheet form or
Verification of No Income form) and supporting documents (pay stubs, tax returns)
Annually updated
Completed Gross Annual Income Worksheet
Completed Adjusted Income /Resident Rent Calculation Worksheet
Date of First Contact:
Date Assistance Started:
Type of Assistance:
Housing Plan and/or Individual Case Management Service Plan
21-Week Tracking Sheet for STRMU assistance (if applicable)
Shared Housing Rent Calculation Worksheet (if applicable)
Expense Verification form and supporting documents (copies of bills for childcare,
medical expenses, telephone and utility charges)
Fair Market Rent (FMR) and Utility Allowance Charts (if applicable)
Income Exclusions list
Landlord rental agreement
Copies of checks paid to landlord
Program service agreement
Housing Inspection Performed – Habitability or HQS form attached, Annually updated
Tenant Inspection Checklist Form Attached
Earned Income Disregard Information and calculations (if applicable)
Lead Based Paint Acknowledgement Form Attached, if housing assistance includes
children under 6 years old or pregnant women
Smoke Detector Certification
Grievances filed, including follow-up and outcomes
Grievance/Termination Policy Signed and Attached
Termination Sheet Attached, if Applicable
Note Other Forms Attached:
Grievance and Termination Policy – Signed as received
Termination Form, if applicable
CASE NOTES:
Sample Form Updated November 2005
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