2013 2014 EMERGENCY SOLUTIONS GRANT GUIDEBOOK ESG Guidelines v2, August 2013 Georgia Department of Community Affairs 2013-2014 Page 1 Guidance for Emergency Solutions Grant As administered by the Department of Community Affairs I. BACKGROUND ON ELIGIBLE ACTIVITIES (PROGRAM TYPES) page 4 a. Emergency Shelter Description page 4 1. Family Separation page 6 2. Minimum Standards for Emergency Shelter page 7 b. Transitional Housing Description (non-ESG funds) page 8 c. Rapid Re-Housing Description page 8 d. Prevention Description page 8 e. Outreach Description page 9 f. Supportive Services Description (non-ESG funds) page 11 g. Project Homeless Connect Description (non-ESG funds) page 11 II. NEW DEFINITION OF HOMELESSNESS, AT RISK OF HOMELESSNESS, AND CHRONIC HOMELESSNESS page 11 III. DOCUMENTATION AND RECORD KEEPING REQUIREMENTS page 14 a. Preferred Order of Documentation page 14 b. Housing Status Documentation and Certification Requirements page 14 IV. INTAKE, ELIGIBILITY ASSESSMENT AND RE-CERTIFICATION page 16 a. Income Eligibility Criteria by Program Type page 17 b. Income Calculations and Changes page 17 c. Re-certification page 18 V. TRAINING page 18 VI. HOUSING SUPPORT STANDARDS page 18 VII. CASE MANAGEMENT page 19 VIII. RENTAL ASSISTANCE REQUIREMENTS page 19 a. Rental Assistance Agreements page 20 b. Late Fees and Leases page 20 c. Rent Reasonableness page 21 d. Fair Market Rent (FMR) page 21 e. Lead Based Paint Disclosure and Remediation page 22 f. Use with Other Subsidies page 23 IX. HOMELESS MANAGEMENT INFORMATION SYSTEM (HMIS) page 23 a. Reporting Requirements page 24 b. Data Quality Checks During Reimbursement Process page 24 c. Data Quality Compliance for Domestic Violence (DV) Service Providers page 24 d. Follow-Up Contact After Program Discharge page 24 X. CONTINUUM OF CARE (CoC) COORDINATION WITH ESG AND CENTRALIZED/COORDINATED INTAKE/ASSESSMENT page 24 XI. PERFORMANCE STANDARDS, MEASURES AND DCA GOALS page 25 XII. REQUIRED WRITTEN STANDARDS page 27 XIII. TERMINATION, COMPLAINTS, APPEALS, AND CONFIDENTIALITY POLICIES page 28 XIV. DCA EDUCATION POLICY page 28 XV. DOCUMENTING PERSONS WITH DISABILITIES page 30 XVI. FAITH-BASED ACTIVITIES page 31 XVII. FORMS APPENDIX page 33 ESG Guidelines v2, August 2013 Page 2 Forms include: A. Intake and Assessment Forms: 1) Intake Form 2) ESG Housing Status Verification, Staff Certification & Self Certification 3) Homeless Definition Criteria and Recordkeeping Fact Sheet 4) Income Verification 5) Self Declaration of Income 6) Prevention Income Calculation Worksheet (can also be used for annual RRH re-certification) 7) Rapid Re-Housing Income Calculation Worksheet 8) Household Recertification B. Property Related Forms: 1) Rental Assistance Agreement 2) Unit Inspection Requirements Fact Sheet 3) Habitability Standards Checklist 4) Rent Reasonableness Checklist and Certification 5) Lead Based Paint Screening Worksheet 6) Lead Based Paint Document Checklist 7) Lead-Based Paint Property Owner Certification Form 8) Understanding the Lead-Based Paint Requirements: Guidance for ESG Grantees 9) Instructions for Property Owners with Tenants Receiving ESG Assistance 10) Instructions for Residents Receiving ESG Assistance C. Sample Documents: 1) HMIS Data Quality Report 2) HMIS Data Cleaning/Reports Guide 3) Sample Lease 4) Sample Policies for Termination, Complaints, Appeals, Confidentiality 5) Vulnerability Index for Street Outreach Programs Note that these Guidelines are based on the best information available at the time of publication. Because of this, they are subject to change at any time. DCA grantees are advised to continuously monitor the ESG Grantees Only website for updates. ESG Guidelines v2, August 2013 Page 3 I. BACKGROUND ON ELIGIBLE ACTIVITIES (PROGRAM TYPES) All recipients of DCA ESG funds are expected to comply with Georgia Balance of State requirements for utilizing the centralized assessment process once procedures are established with the Continuum of Care (CoC). Grantees are required to comply with all ESG requirements including; the provision of case management, helping program participants increase income, either via employment assistance or through the acquisition of mainstream benefits, and helping program participants move into and stay in permanent housing. a. Emergency Shelter From the new ESG regulations, "emergency shelter means any facility, the primary purpose of which is to provide a temporary shelter for the homeless in general or for specific populations of the homeless and which does not require occupants to sign leases or occupancy agreements." Shelter stays should be avoided, if possible, and when not possible, limited to the shortest time necessary to help participants regain permanent housing. Emergency shelter programs should be closely linked to an array of programs in order to accomplish this goal of stable permanent housing including, but not limited to, rapid re-housing, transitional housing, affordable housing placement, and employment. Linkages should also be made to applicable mainstream programs such as SOAR, food stamps, TANF, etc. (1) Subject to DCA approval within your Program Participation Agreement, ESG funds may be used for costs of providing essential services to homeless families and individuals in emergency shelters and operating emergency shelters. a. Case management. The cost of assessing, arranging, coordinating, and monitoring the delivery of individualized services to meet the needs of the program participant is eligible. Component services and activities consist of: (A) Using the centralized or coordinated assessment system as required under 576.400(d); (B) Conducting the initial evaluation required under 576.401(a), including verifying and documenting eligibility; (C) Counseling; (D) Developing, securing, and coordinating services and obtaining Federal, State, and local benefits; (E) Monitoring and evaluating program participant progress; (F) Providing information and referrals to other providers; (G) Providing ongoing risk assessment and safety planning with victims of domestic violence, dating violence, sexual assault, and stalking; and (H) Developing an individualized housing and service plan, including planning a path to permanent housing stability. b. Child care. The costs of child care for program participants, including providing meals and snacks, and comprehensive and coordinated sets of appropriate developmental activities, are eligible. The children must be under the age of 13, unless they are disabled. Disabled children must be under the age of 18. The child-care center must be licensed by the jurisdiction in which it operates in order for its costs to be eligible. c. Education services. When necessary for the program participant to obtain and maintain housing, the costs of improving knowledge and basic educational skills are eligible. Services include instruction or training in consumer education, health education, substance abuse prevention, literacy, English as a Second Language, and General Educational Development (GED). Component services or activities are screening, assessment and testing; individual or group instruction; tutoring; provision of books, supplies and instructional material; counseling; and referral to community resources. d. Employment assistance and job training. The costs of employment assistance and job training programs are eligible, including classroom, online, and/or computer instruction; on-the-job instruction; and services that assist individuals in securing employment, acquiring learning skills, and/or increasing earning potential. Learning skills include those skills that can be used to secure and ESG Guidelines v2, August 2013 Page 4 retain a job. Services that assist individuals in securing employment consist of employment screening, assessment, or testing; structured job skills and job-seeking skills; special training and tutoring, including literacy training and prevocational training; books and instructional material; counseling or job coaching; and referral to community resources. e. Outpatient health services. Eligible costs are for the direct outpatient treatment of medical conditions and are provided by licensed medical professionals. Emergency Solutions Grant (ESG) funds may be used only for these services to the extent that other appropriate health services are unavailable within the community. Eligible treatment consists of assessing a program participant's health problems and developing a treatment plan; assisting program participants to understand their health needs; providing directly or assisting program participants to obtain appropriate medical treatment, preventive medical care, and health maintenance services, including emergency medical services; providing medication and follow-up services; and providing preventive and non-cosmetic dental care. f. Legal services. (A) Eligible costs are the hourly fees for legal advice and representation by attorneys licensed and in good standing with the bar association of the State in which the services are provided, and by person(s) under the supervision of the licensed attorney, regarding matters that interfere with the program participant's ability to obtain and retain housing. (B) Emergency Solutions Grant (ESG) funds may be used only for these services to the extent that other appropriate legal services are unavailable or inaccessible within the community. (C) Eligible subject matters are child support, guardianship, paternity, emancipation, and legal separation, orders of protection and other civil remedies for victims of domestic violence, dating violence, sexual assault, and stalking, and appeal of veterans and public benefit claim denials. (D) Component services or activities may include client intake, preparation of cases for trial, provision of legal advice, representation at hearings, and counseling. (E) Fees based on the actual service performed (i.e., fee for service) are also eligible, but only if the cost would be less than the cost of hourly fees. Filing fees and other necessary court costs are also eligible. If the grantee is a legal services provider and performs the services itself, the eligible costs are the grantee's employees' salaries and other costs necessary to perform the services. (F) Legal services for immigration and citizenship matters and issues relating to mortgages are ineligible costs. Retainer fee arrangements and contingency fee arrangements are ineligible costs. g. Life skills training. The costs of teaching critical life management skills that may never have been learned or have been lost during the course of physical or mental illness, domestic violence, substance use, and homelessness are eligible costs. These services must be necessary to assist the program participant to function independently in the community. Component life skills training are budgeting resources, managing money, managing a household, resolving conflict, shopping for food and needed items, improving nutrition, using public transportation, and parenting. h. Mental health services. (A) Eligible costs are the direct outpatient treatment by licensed professionals of mental health conditions. (B) ESG funds may only be used for these services to the extent that other appropriate mental health services are unavailable or inaccessible within the community. (C) Mental health services are the application of therapeutic processes to personal, family, situational, or occupational problems in order to bring about positive resolution of the problem or improved individual or family functioning or circumstances. Problem areas may include family and marital relationships, parent-child problems, or symptom management. (D) Eligible treatment consists of crisis interventions; individual, family, or group therapy sessions; the prescription of psychotropic medications or explanations about the use and management of medications; and combinations of therapeutic approaches to address multiple problems. ESG Guidelines v2, August 2013 Page 5 i. Substance abuse treatment services. (A) Eligible substance abuse treatment services are designed to prevent, reduce, eliminate, or deter relapse of substance abuse or addictive behaviors and are provided by licensed or certified professionals. (B) ESG funds may only be used for these services to the extent that other appropriate substance abuse treatment services are unavailable or inaccessible within the community. (C) Eligible treatment consists of client intake and assessment, and outpatient treatment for up to 30 days. Group and individual counseling and drug testing are eligible costs. Inpatient detoxification and other inpatient drug or alcohol treatment are not eligible costs. j. Transportation. Eligible costs consist of the transportation costs of a program participant's travel to and from medical care, employment, child care, or other eligible essential services facilities. These costs include the following: (A) The cost of a program participant's travel on public transportation; (B) If service workers use their own vehicles, mileage allowance for service workers to visit program participants; (C) The cost of purchasing or leasing a vehicle for the recipient or grantee in which staff transports program participants and/or staff serving program participants, and the cost of gas, insurance, taxes, and maintenance for the vehicle; and (D) The travel costs of recipient or grantee staff to accompany or assist program participants to use public transportation. k. Shelter operations. Eligible costs are the costs of maintenance (including minor or routine repairs), rent, security, fuel, equipment, insurance, utilities, food, furnishings, and supplies necessary for the operation of the emergency shelter. Where no appropriate emergency shelter is available for a homeless family or individual, eligible costs may also include a hotel or motel voucher for that family or individual. a.1. Family Separation and Emergency Shelter HUD issued regulations that all shelters are prohibited from denying access to families based on the age of a child. This requirement has been issued through the HEARTH Act and through the ESG Interim Rule. All DCA funded emergency shelters and transitional housing facilities will comply with this requirement. Non- compliance may result in removal of ESG funds. Please see the following for specific information. HEARTH Act language on family separation: `SEC. 404. PREVENTING INVOLUNTARY FAMILY SEPARATION. ``(a) IN GENERAL.--... any project sponsor receiving funds under this title to provide emergency shelter, transitional housing, or permanent housing to families with children under age 18 shall not deny admission to any family based on the age of any child under age 18. ``(b) EXCEPTION.--Notwithstanding the requirement under subsection (a), project sponsors of transitional housing receiving funds under this title may target transitional housing resources to families with children of a specific age only if the project sponsor-- ``(1) operates a transitional housing program that has a primary purpose of implementing an evidence-based practice that requires that housing units be targeted to families with children in a specific age group; and ``(2) provides such assurances, as the Secretary shall require, that an equivalent appropriate alternative living arrangement for the whole family or household unit has been secured." ESG Interim Rule language on family separation: "(b) Prohibition against involuntary family separation. The age, of a child under age 18 must not be used as a basis for denying any family's admission to an emergency shelter that uses Emergency Solutions Grant (ESG) funding or services and provides shelter to families with children under age 18." ESG Guidelines v2, August 2013 Page 6 a.2. Minimum Standards for Emergency Shelter Any emergency shelter that receives ESG assistance for shelter operations must meet the following minimum safety, sanitation, and privacy standards. Grantees may also establish standards that exceed or add to these minimum standards. 1. Structure and materials The shelter building must be structurally sound to protect residents from the elements and not pose any threat to health and safety of the residents. 2. Access The shelter must be accessible in accordance with Section 504 of the Rehabilitation Act (29 U.S.C. 794) and implementing regulations at 24 CFR part 8; the Fair Housing Act (42 U.S.C. 3601 et seq.) and implementing regulations at 24 CFR part 100; and Title II of the Americans with Disabilities Act (42 U.S.C. 12131 et seq.) and 28 CFR part 35; where applicable. 3. Space and security Except where the shelter is intended for day use only, the shelter must provide each program participant in the shelter with an acceptable place to sleep and adequate space and security for themselves and their belongings. 4. Interior air quality Each room or space within the shelter must have a natural or mechanical means of ventilation. The interior air must be free of pollutants at a level that might threaten or harm the health of residents. 5. Water supply The shelter's water supply must be free of contamination. 6. Sanitary facilities Each program participant in the shelter must have access to sanitary facilities that are in proper operating condition, are private, and are adequate for personal cleanliness and the disposal of human waste. 7. Thermal environment The shelter must have any necessary heating/ cooling facilities in proper operating condition. 8. Illumination and electricity The shelter must have adequate natural or artificial illumination to permit normal indoor activities and support health and safety. There must be sufficient electrical sources to permit the safe use of electrical appliances in the shelter. 9. Food preparation Food preparation areas, if any, must contain suitable space and equipment to store, prepare, and serve food in a safe and sanitary manner. 10. Sanitary conditions The shelter must be maintained in a sanitary condition. ESG Guidelines v2, August 2013 Page 7 11. Fire safety There must be at least one working smoke detector in each occupied unit of the shelter. Where possible, smoke detectors must be located near sleeping areas. The fire alarm system must be designed for hearing- impaired residents. All public areas of the shelter must have at least one working smoke detector. There must also be a second means of exiting the building in the event of fire or other emergency. b. Transitional Housing Transitional housing (TH) is designed to meet more intensive service needs to increase the housing stability of the population served. Transitional Housing stays are typically between 90 days and 2 years. Providers should link program participants to applicable mainstream programs such as SOAR, food stamps, TANF, etc. with the goal of helping participants secure permanent housing. Funding for TH is being provided by the State. Outreach providers should collaborate with TH providers to secure housing for clients coming from the street who need temporary housing and have significant barriers to housing stability. Rapid re-housing providers should collaborate with TH providers to identify RRH program participants. c. Rapid Re-Housing Rapid Re-Housing programs are designed to help those who are homeless transition into permanent housing. The primary goal is to stabilize a program participant in permanent housing as quickly as possible and to provide wrap-around services after the family or individual obtains housing. Households receiving this funding must have an income level at or below 50% AMI. Enrollment in a rapid re-housing program should rely heavily on a case management plan to ensure long term stability for program participants. Providers are expected to implement a case management plan that will increase household incomes and/or increase access to mainstream benefits for program participants. Linkages should also be made to applicable mainstream programs such as SOAR, food stamps, TANF, etc. By ESG regulation at 24 CFR 576, ESG funds may be used to provide housing relocation and stabilization services and short- and/or medium-term rental assistance as necessary to help a homeless individual or family move as quickly as possible into permanent housing and achieve stability in that housing. Rapid re-housing assistance must be provided in accordance with the housing relocation and stabilization services requirements in 576.105, the short- and medium term rental assistance requirements in 576.106, and the written standards and procedures established under 576.400. Contracts issued by DCA for this program will begin on July 1st each year and run for a period of 15 months, through September 30, to avoid lapses in service coverage. d. Homelessness Prevention Prevention is most efficiently implemented when targeted to those at greatest risk of losing housing. Households receiving this funding must have an income level below 30% AMI and must demonstrate that they do not have sufficient resources or support networks to prevent them from moving to an emergency shelter or other place defined under Category 1 of the homeless definition. Enrollment in a prevention program should typically last around 2-6 months, although enrollments can be longer, and rely heavily on a case management plan to ensure long term stability for program participants. Grantees should negotiate with landlords as the first step in resolving eviction crises. Prevention implementations should effectively target households at greatest risk of homelessness and assist participants to increase household incomes during ESG Guidelines v2, August 2013 Page 8 enrollment. Linkages should also be made to applicable mainstream programs such as SOAR, food stamps, TANF, etc. By regulation, ESG funds may be used to provide housing relocation and stabilization services and short- and/or medium-term rental assistance necessary to prevent an individual or family from moving into an emergency shelter or another place described in paragraph (1) of the ``homeless'' definition in 576.2. The costs of homelessness prevention are only eligible to the extent that the assistance is necessary to help the program participant regain stability in the program participant's current permanent housing or move into other permanent housing and achieve stability in that housing. Contracts issued by DCA for this program will begin on July 1st each year and run for a period of 15 months, through September 30, to avoid lapses in service coverage. e. Street Outreach ESG funds may be used for costs of providing essential services necessary to reach out to unsheltered homeless people; connect them with emergency shelter, housing, or critical services; and provide urgent, non facility-based care to unsheltered homeless people who are unwilling or unable to access emergency shelter, housing, or an appropriate health facility. The term ``unsheltered homeless people'' is defined as (1) An individual or family who lacks a fixed, regular, and adequate nighttime residence, meaning: (i) An individual or family with a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings, including a car, park, abandoned building, bus or train station, airport, or camping ground;... There are 6 eligible activities for Street Outreach, as follows: 1. Engagement the location, identification and relationship building with unsheltered homeless people and the engagement of them for the purpose of providing immediate support, intervention, and connections with homeless assistance programs and/or mainstream social services and housing programs. Eligible activities include assessment of needs and eligibility; providing crisis counseling; addressing urgent physical needs, and actively connecting and providing information and referrals to programs targeted to homeless people and mainstream social services and housing programs. Eligible costs include the cell phone costs of outreach workers during the performance of these activities. 2. Case management the assessment of housing and service needs, and implementing individualized services to meet the needs of the program participant. Eligible services and activities are as follows: using the centralized or coordinated assessment system as required under 576.400(d); conducting the initial evaluation required under 576.401(a), including verifying and documenting eligibility; counseling; developing, securing and coordinating services; obtaining Federal, State, and local benefits; monitoring and evaluating program participant progress; providing information and referrals to other providers; and developing an individualized housing and service plan, including planning a path to permanent housing stability. 3. Emergency health services. Eligible costs are for the direct outpatient treatment of medical conditions and are provided by licensed medical professionals operating in community-based settings, including streets, parks, and other places where unsheltered homeless people are living. Eligible treatment consists of developing a treatment plan; assisting program participants to understand their health needs; providing directly or obtaining emergency medical treatment; and providing medication and follow-up services. ESG Guidelines v2, August 2013 Page 9 4. Emergency mental health services. Eligible costs are the direct outpatient treatment by licensed professionals of mental health conditions operating in community-based settings, including streets, parks, and other places where unsheltered people are living. of the problem or improved individual or family functioning or circumstances. (iv) Eligible treatment consists of crisis interventions, and the prescription and management of psychotropic medications. 5. Transportation. The transportation costs of travel by outreach workers, social workers, medical professionals, or other service providers are eligible, provided that this travel takes place during the provision of services eligible under this section. The costs of transporting unsheltered people to emergency shelters or other service facilities are also eligible. 6. Services for special populations. ESG funds may be used to provide services for homeless youth, victim services, and services for people living with HIV/AIDS, so long as the costs of providing these services are eligible under paragraphs (a)(1) through (a)(5) of this section. Implementation of Street Outreach DCA anticipates and expects the bulk of all Street Outreach awards to be spent on street based Engagement and Case Management. Should any Grantee wish to spend any significant amount of funds on any other eligible activity, they should contact DCA to discuss this and receive written approval from DCA before making any decisions. Grantees should note that activities 3 and 4 refer to Emergency Health and Mental Health services, rather than services that may be delivered on a routine basis. Street Outreach should be principally focused to one goal: that of supporting homeless households in achieving some form of permanent, sustainable housing. While Street Outreach teams may use incentives to encourage trust and build relationships, or to ensure that homeless households' emergency needs are met, the awards made should not be used to support other programs that seek to alleviate the burden of living on the streets. Outreach programs should consider the use of an assessment form in addition to Barriers to Housing Stability, one that is more suited to a street assessment. This should include the options of diversion and placements directly into permanent housing. At this time DCA is not mandating the use of any specific assessment tool, but assessments such as the Vulnerability Index have value in assisting Street Outreach staff in placing homeless individuals and families. Outreach teams will have the most comprehensive knowledge of street based individuals / households within the locality. Outreach teams will be responsible for ensuring that a case plan is established for each household that is client centered, realistic and focused towards a goal of permanent housing. Where one or more Outreach teams work in the same area, DCA expects that agencies collaborate to provide complimentary services by: 1. Establishing a lead person / agency that will promote an agreed intervention for the individual / family. 2. The agency will lead the case management of the homeless individual until either the individual has been re-housed, or a more appropriate case manager is ready to take over. 3. Other agencies will reinforce this intervention so that agencies are not working against one another. Outreach teams will be expected to establish close working relationships with other service providers, not only Emergency Shelters, but other mainstream and housing focused services, such as Rapid Re-Housing. Not every ESG Guidelines v2, August 2013 Page 10 homeless household is expected to need admittance to an emergency shelter and Street Outreach teams should be prepared to implement a variety of interventions in securing permanent housing. f. Supportive Services Only Programs A Supportive Services Only program is defined by DCA to be a distinct initiative undertaken by a grantee to provide supportive services directly to "homeless" persons (by HUD definition) living in unsheltered environments or in homeless housing programs. Services must be collaborative and available to a network of identified homeless service agencies throughout the service area. To be eligible for Supportive Services funds, persons served, or a majority of persons served, are not also housed by the Applicant with ESG funds. Funding for Services programs is being provided using State funds. Linkages should also be made to applicable mainstream programs such as SOAR, food stamps, TANF, etc. DCA awards funds for programs with the overall objective of assisting them into permanent housing. g. Project Homeless Connect Project Homeless Connect (PHC) is a one-day, one-stop event that will deliver services to people experiencing homelessness in the community. These events are designed to facilitate understanding and cooperation among homeless service providers, volunteers, homeless individuals and families, community leaders, local government, housing agencies, funding agencies, human service agencies, ecumenical groups and others with an interest in homeless issues. A PHC event makes a difference in the lives of homeless people by engaging them in the community. At a minimum, the event should provide an array of social services including healthcare, legal aid, housing assistance, job opportunities, benefits enrollment opportunities and quality of life resources with the underlying idea to get as many as possible on a track to self-sufficiency and into permanent housing. Outreach, emergency shelter, rapid re-housing, and transitional housing programs should collaborate with local PHC events. Every effort should be made to input relevant client data into HMIS. II. NEW DEFINITION OF HOMELESSNESS, AT RISK OF HOMELESSNESS, AND CHRONIC HOMELESSNESS HOMELESS There are FOUR definitions of homelessness: CATEGORY 1: An individual or family who lacks a fixed, regular, and adequate nighttime residence. {Qualifies for Emergency Shelter, Rapid Re-Housing, Transitional Housing, Outreach, Supportive Services programs} An individual or family: (A) With a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings, including a car, park, abandoned building, bus or train station, airport, or camping ground (B) Living in a supervised publicly or privately operated shelter designated to provide temporary living arrangements (including congregate shelters, transitional housing, and hotels and motels paid for by charitable organizations or by federal, state, or local government programs for low-income individuals) or (C) Who is exiting an institution where he or she 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. ESG Guidelines v2, August 2013 Page 11 CATEGORY 2: An individual or family who will imminently lose their primary nighttime residence provided for whom: {Qualifies for Emergency Shelter, Transitional Housing, Prevention programs} (A) The residence will be lost within 14 days of the date of application for homeless assistance; (B) No subsequent residence has been identified; and (C) The individual or family lacks the resources or support networks, [e.g., family, friends, faith-based or other social networks needed to obtain other permanent housing] CATEGORY 3: Unaccompanied youth under 25 years of age, or families with children and youth, who do not otherwise qualify as homeless, but who meet the following four (4) criteria: (i) Are defined as homeless under other legislation including: Section 387 of the Runaway and Homeless Youth Act (42 U.S.C. 5732a) Section 637 of the Head Start Act (42 U.S.C. 9832) Section 41403 of the Violence Against Women Act of 1994 (42 U.S.C. 14043e2) Section 330(h) of the Public Health Service Act (42 U.S.C. 254b(h) Section 3 of the Food and Nutrition Act of 2008 (7 U.S.C. 2012) Section 17(b) of the Child Nutrition Act of 1966 (42 U.S.C. 1786(b) OR Section 725 of the McKinney-Vento Homeless Assistance Act (42 U.S.C. 11434a); (ii) Have not had a lease, ownership interest, or occupancy agreement in permanent housing at any time during the 60 days immediately preceding the date of application for homeless assistance; (iii) Have experienced persistent instability as measured by two moves or more during the 60-day period immediately preceding the date of applying for homeless assistance; AND (iv) Can be expected to continue in such status for an extended period of time because of chronic disabilities, chronic physical health or mental health conditions, substance addiction, histories of domestic violence or childhood abuse (including neglect), the presence of a child or youth with a disability, or two or more barriers to employment, which include the lack of a high school degree or General Education Development (GED), illiteracy, low English proficiency, a history of incarceration or detention for criminal activity, and a history of unstable employment. CATEGORY 4: Any individual or family who: {Qualifies for Emergency Shelter, Transitional Housing, Rapid Re-Housing if they also meet CATEGORY 1} (A) Is fleeing, or is attempting to flee; domestic violence, dating violence, sexual assault, stalking, or other dangerous or life-threatening conditions that relate to violence against the individual or a family member, including a child, that has either taken place within the individual's or family's primary nighttime residence or has made the individual or family afraid to return to their primary nighttime residence; (B) Has no other residence; and (C) Lacks the resources or support networks, e.g., family, friends, faith-based or other social networks, to obtain other permanent housing. AT RISK OF HOMELESSNESS To qualify, the individual or family must meet two threshold criteria and must exhibit one or more specified risk factors. The two threshold criteria are below. ESG Guidelines v2, August 2013 Page 12 The individual or family must have: 1. Income below 30 percent of median income for the geographic area; AND 2. Insufficient resources immediately available to attain housing stability. [e.g., family, friends, faith-based or other social networks immediately available] to prevent them from moving to an emergency shelter or another place described in category 1 of the homeless definition. Risk factors are: (A) Has moved frequently because of economic reasons--``2 or more times during the 60 days immediately preceding the application for homelessness prevention assistance.'' (B) Is living in the home of another because of economic hardship 1 (C) Has been notified in writing that their right to occupy their current housing or living situation will be terminated within 21 days after the date of application. (D) Lives in a hotel or motel; [``and the cost of the hotel or motel is not paid for by federal, state, or local government programs for low-income individuals or by charitable organizations.''] (E) Lives in severely overcrowded housing; [in a single-room occupancy or efficiency apartment unit in which more than two persons, on average, reside or another type of housing in which there reside more than 1.5 persons per room, as defined by the U.S. Census Bureau.] (F) Is exiting a publicly funded institution; or system of care, [such as a health-care facility, mental health facility, foster care or other youth facility, or correction program or institution.] (G) Otherwise lives in housing that has characteristics associated with instability and an increased risk of homelessness. (Use the characteristics described in your jurisdictions Consolidated Plan). The DCA Consolidated Plan describes housing characteristics linked with instability and an increased risk of homelessness in the following way: For the purposes of Georgia's Consolidated Plan, the number of households with incomes below 30% of the median family income and who spend more than 50% of their income on housing is used as a proxy for the number of households threatened with homelessness. This proxy matches the statistics indicating that most households, immediately prior to becoming homeless, spend as much as 70% of their income on housing. Extremely low income households threatened with homelessness require a variety of supportive services to meet their respective needs, including rental/mortgage assistance; security deposit and utility assistance; financial management counseling; landlord-tenant counseling; day care; job counseling; substance abuse counseling; and medical services. CHRONIC HOMELESS An "individual" or "family" who is ... literally homeless and has been such for at least one year or on at least four separate occasions in the last 3 years, where each occasion lasted for at least 15 days. Continuously unsheltered or in a shelter for past 1 year, or this is the 4th separate occurrence of this living situation in the past 3 years; AND Head of household has a specific (see regulations) disability. A person who currently lives or resides in an institutional care facility, including a jail, substance abuse or mental health treatment facility, hospital or other similar facility, and has resided there for fewer than 90 days 1 HUD is considering whether and how to clarify ``economic reasons'' in the first risk factor and ``economic hardship'' in the second risk factor. ESG Guidelines v2, August 2013 Page 13 shall be considered "chronically homeless" if such person met all of the requirements described above prior to entering that facility. III. DOCUMENTATION AND RECORD KEEPING REQUIREMENTS Grantees must keep ESG records for 5 years after the expenditure of all funds from the grant. HOUSING STATUS DOCUMENTATION ESG grantees must establish and follow written intake procedures to ensure program compliance. The procedures must require documentation at intake of the evidence relied upon to establish and verify homeless, at-risk or domestic violence status. THIRD PARTY SOURCE DOCUMENTS ARE THE PREFERRED METHOD OF VERIFYING AND DOCUMENTING HOUSING STATUS. a. Preferred Order of Documentation The order of priority for evidence establishing and verifying homeless status is: 1. Third-party documentation source documents provided by an outside source 2. Staff/Intake worker observation documented by ESG staff 3. Certification from the person seeking assistance ESG staff must certify efforts made to obtain third party documentation before allowing applicant to self-certify Lack of third party documentation must not prevent an individual or family from being immediately admitted to emergency shelter, receiving street outreach services, or being immediately admitted to shelter or receiving services provided by a victim service provider. b. Housing Status Documentation Requirements and Certification Requirements Homeless CATEGORY 1 acceptable evidence includes: 1. DCA Housing Status Verification and Self Certification (by the head of household seeking assistance) Forms 2. HMIS Verification of Homelessness HMIS or ALICE can be used to verify homelessness by accessing a client record, determining that the ESG applicant is (at the time of application for ESG funds) enrolled in a program for homeless individuals or families, and printing a screen shot of that HMIS/ALICE evidence for the file. This method will primarily be used by rapid re-housing providers. OR 3. A written observation by an outreach worker of the conditions where the individual or family was living, a written referral by another housing or service provider. Homeless CATEGORY 1 and is exiting an institution where he or she resided for 90 days or less, acceptable evidence includes: 1. Evidence listed above for CATEGORY 1 AND ONE of the following: (A) Discharge paperwork or a written or oral referral from a social worker, case manager, or other appropriate official of the institution, stating the beginning and end dates of the time residing in the institution. All oral statements must be recorded by the intake worker; OR (B) Where the evidence listed above in (A) is not obtainable, a written record of the intake worker's due diligence in attempting to obtain the evidence described in (A) and a certification by the individual seeking ESG Guidelines v2, August 2013 Page 14 assistance that states he or she is exiting or has just exited an institution where he or she resided for 90 days or less. Homeless CATEGORY 2 evidence includes: 1. A court order resulting from an eviction action that requires the individual or family to leave their residence within 14 days after the date of their application for homeless assistance OR 2. The equivalent notice under applicable state law, a Notice to Quit, or a Notice to Terminate issued under state law. For applicants whose primary nighttime residence is a hotel or motel room not paid for by charitable organizations or federal, state, or local government programs: A. Evidence that the individual or family lacks the resources necessary to reside there for more than 14 days after the date of application for homeless assistance OR B. An oral statement by the individual or head of household that the owner or renter of the housing in which they currently reside will not allow them to stay for more than 14 days after the date of application for homeless assistance. The intake worker must record the statement and certify that it was found credible. To be found credible, the oral statement must either: Be verified by the owner or renter of the housing in which the individual or family resides at the time of application for homeless assistance AND Be documented by a written certification by the owner or renter or by the intake worker's recording of the owner or renter's oral statement. If the intake worker is unable to contact the owner or renter: 1) The intake worker must provide written documentation certifying that he/she performed due diligence in attempting to obtain verification and written certification that the applicant's statement was true and complete. 2) Certification by the individual or head of household that no subsequent residence has been identified; AND 3) Certification or other written documentation that the individual or family lacks the resources and support networks needed to obtain other permanent housing. Homeless CATEGORY 4: Acceptable evidence includes: If the individual or family is receiving shelter or services provided by a victim service provider: 1. DCA Housing Status Self Certification Form; OR 2. A certification by the intake worker. ESG Guidelines v2, August 2013 Page 15 Otherwise: a. The DCA Housing Status Self Certification Form documenting that applicant is fleeing a domestic violence situation, has not identified a subsequent residence, and lacks the resources or support networks, e.g., family, friends, faith-based, or other social networks, needed to obtain housing where his/her safety would not be jeopardized AND b. Written observation by the intake worker, a written referral by a housing or service provider, social worker, legal assistance provider, health-care provider, law enforcement agency, legal assistance provider, pastoral counselor, or any other organization from whom the individual or head of household has sought assistance for domestic violence, or records contained in ALICE. AT RISK OF HOMELESSNESS: Acceptable evidence includes: 1. When determining the annual income of an individual or family, the recipient or grantee must use the standard for calculating annual income under 24 CFR 5.609. Check guidance for further evidence requirements. 2. Evidence of the second eligibility criterion ("lacks sufficient resources...") is: c. Source documents - notice of termination from employment, unemployment compensation statement, bank statement, health-care bill showing arrears, utility bill showing arrears. d. To the extent that source documents are unobtainable, a written statement by the relevant third party - (e.g., former employer, public administrator, relative) or written certification by the intake staff of the oral verification by the relevant third party that the applicant meets one or both of the criteria of the definition of ``at risk of homelessness'' OR e. If source documents and third-party verification are unobtainable, a written statement by intake staff describing the efforts taken to obtain the required evidence. 3. Evidence for documenting at least one of the 7 risk factors is: f. Source documents (notice of termination from employment, unemployment compensation statement, bank statement, health-care bill showing arrears, utility bill showing arrears). g. To the extent that source documents are unobtainable, a written statement by the relevant third party - (e.g., former employer, public administrator, relative) or written certification by the intake staff of the oral verification by the relevant third party that the applicant meets one or both of the criteria of the definition of ``at risk of homelessness'' or h. If source documents and third-party verification are unobtainable, a written statement by intake staff describing the efforts taken to obtain the required evidence. (can include staff visit to applicant home to verify eligibility) IV. INTAKE, ELIGIBILITY ASSESSMENT AND RE-CERTIFICATION Intake All ESG applicants must participate in an initial consultation to assess needs and to determine program eligibility. The consultation will include; verification of homelessness status or risk for homelessness, ESG Guidelines v2, August 2013 Page 16 applicant's barriers to housing stability, collection of HMIS universal data elements, and program elements as necessary. Grantees will complete the following procedures: Check HMIS (or ALICE) to determine if the applicant is currently receiving assistance from any other federal funding sources. Clients cannot receive funding for duplicate services at the same time. A printed HMIS screen can be used as documentation in the applicant's file. Collect the required ESG documentation (evidence to establish and verify the client's housing status; copy of documentation to establish annual income; certification that client has insufficient support networks; etc.) as relevant. Case Manager will record required HMIS data in the Pathways COMPASS system (or ALICE) for all program participants. If client is not eligible for ESG, DCA ESG grantees are required to include documentation regarding non-eligibility and to identify other appropriate service providers within the Continuum that can more effectively meet the applicant's needs. a. Eligibility Assessment for Emergency Shelter, Transitional Housing and Outreach Eligibility for these programs requires a verification of homelessness. See previous section on documenting housing status. There are no income eligibility requirements for emergency shelter, transitional housing, outreach, or supportive services grants. b. Income Eligibility Criteria for Prevention and Rapid Re-Housing To qualify for DCA Rapid Re-Housing funding the household income must be: at or below 50 percent AMI for the geographic area. To qualify for DCA Prevention funding the household income must be: below 30 percent AMI for the geographic area. Area Median Income is defined by HUD and updated annually. The most recent guidelines should be used each year. The following site can be accessed to determine AMI: http://www.huduser.org/portal/datasets/il/il13/index.html Documentation that applicants meet income eligibility guidelines is required for Prevention and Rapid Re- Housing programs. Worksheets have been created to help grantees determine and document eligibility for both programs. A sample is contained in the "Forms" section of this guide and electronic versions are located on the DCA ESG "Grantees Only" webpage. Total household income should include allowable sources from all household members. c. Income Calculations and Changes Income Calculations Income calculations are modeled after the requirements for the HOME Investment Partnerships program (24 CFR 92.508) and other HUD regulations. Guidance is located here: http://www.gpo.gov/fdsys/pkg/CFR-2012-title24-vol1/pdf/CFR-2012-title24-vol1-sec92-508.pdf Income inclusions and Exclusions: http://portal.hud.gov/hudportal/documents/huddoc?id=DOC_35699.pdf ESG Guidelines v2, August 2013 Page 17 General income information: http://portal.hud.gov/hudportal/HUD?src=/program_offices/comm_planning/affordablehousing/training/ web/calculator/requirements/verifying Changes in Income The grantee should require each program participant receiving homelessness prevention or rapid re-housing assistance to notify the grantee regarding changes in the program participant's income or other circumstances (e.g., changes in household composition) that affect the program participant's need for assistance under ESG. When notified of a relevant change, the grantee must re-evaluate the program participant's eligibility and the amount and types of assistance the program participant needs. d. Re-Certification Re-certification determines whether or not an individual or family is still eligible for a program and is required for Prevention and Rapid Re-Housing programs. It occurs: Every 90 days after program enrollment date AND Annually for those enrolled in program 1 year after initial enrollment date. 90 Day Re-certification for Rapid Re-Housing includes determination that the household: 1. Is at or below 50% AMI 2. Is at risk of returning to homelessness 3. Lacks the financial resources and support networks needed to obtain housing or remain in their housing **NOTE: FOR RAPID RE-HOUSING ANNUAL RE-CERTIFICATIONS, HOUSEHOLDS MUST HAVE AN INCOME BELOW 30% AMI. THIS IS REQUIRED BY LAW AND IS DIFFERENT FROM THE ELIGIBILITY AND 90 DAY RE- CERTIFICATION CRITERIA! 90 and 365 Day Re-certifications for Prevention includes determination that the household: 1. Is below 30% AMI. 2. Remains at-risk of homelessness 3. Lacks the financial resources and support networks needed to remain in their housing *A fourth month of assistance cannot be issued until re-certification is complete. V. TRAINING DCA will provide training for ESG sub-recipients primarily in the first half of the grant year. Trainings are required and will consist of Program Implementation workshops, Rapid Re-Housing trainings, Housing First Case management trainings, Housing Support Standards and more. All agencies are required to participate in Housing First Case Management and Housing Support Standards trainings. Other training sessions must be attended by agencies according to the relevancy of topics offered. Trainings will be posted on the ESG Grantees Only webpage. VI. HOUSING SUPPORT STANDARDS All recipients of ESG funding must meet DCA standards for housing support services. Utilizing a strengths- based approach to promote housing stability, the standards are guided by a philosophy that values participant ESG Guidelines v2, August 2013 Page 18 (meaning clients, consumers, etc.) choice within an atmosphere that promotes respect between staff and participant. The standards will inform processes within your program such as intake and assessment, service delivery and post discharge follow up. To ensure compliance with this policy please become familiar with the standards on the DCA website. DCA staff will also offer Housing Support Standards trainings for ESG sub-grantees. VII. CASE MANAGEMENT DCA grantees are expected to provide case management to all ESG program participants, including connecting program participants to mainstream and other resources. Grantees should use www.compass.ga.gov to screen for eligibility and apply for mainstream benefits on behalf of or with program participants. Grantees must assist each program participant, as needed, to obtain: 1) Appropriate supportive services, including assistance in obtaining permanent housing, medical health treatment, mental health treatment, counseling, supervision, and other services essential for achieving independent living; and 2) Other Federal, State, local, and private assistance available to assist the program participant in obtaining housing stability, including: A. Medicaid (42 CFR chapter IV, subchapter C): B. Supplemental Nutrition Assistance Program (7 CFR parts 271 283); C. Women, Infants and Children (WIC) (7 CFR part 246); D. Federal-State Unemployment Insurance Program (20 CFR parts 601 603, 606, 609, 614617, 625, 640, 650); E. Social Security Disability Insurance (SSDI) (20 CFR part 404); F. Supplemental Security Income (SSI) (20 CFR part 416); G. Child and Adult Care Food Program (42 U.S.C. 1766(t) (7 CFR part 226)); H. Other assistance available under the programs listed in 576.400(c). Prevention and Rapid Re-Housing Case Management Housing stability case management is required of grantees providing homelessness prevention or rapid re- housing assistance. Grantees must: 1. Require the program participant to meet with a case manager not less than once per month to assist the program participant in ensuring long-term housing stability; AND 2. Develop a plan to assist the program participant to retain permanent housing after the ESG assistance ends, taking into account all relevant considerations, such as the program participant's current or expected income and expenses; other public or private assistance for which the program participant will be eligible and likely to receive; and the relative affordability of available housing in the area. VIII. RENTAL ASSISTANCE REQUIREMENTS DCA will not establish a mandatory share of rent and utility costs that program participants must contribute while in rapid re-housing and prevention programs. DCA will rely on the best judgment of grantees to determine households for whom this approach is reasonable. We will also rely on grantee judgment to determine reasonable amounts in those cases. Grantees will be expected to develop policies and procedures ESG Guidelines v2, August 2013 Page 19 using the guidance provided by DCA as the minimum standard. Examination of policies and procedures will be conducted by DCA staff during monitoring visits. Because ESG funding is awarded on an annual basis, DCA will not allow program participants to receive rental assistance from grantees for more than 12 months during a particular grant year. DCA reserves the right to make an exception to this rule in extreme cases in which grantees provide evidence that the participant's welfare is endangered without access to this assistance. DCA also reserves the right to re-visit this policy upon making changes to its funding allocation cycle. Rental Assistance Agreements Short- and medium-term rental assistance programs require that a program participant and a housing owner have a written lease for the provision of rental assistance. In addition, the interim rule also requires a rental assistance agreement between the grantee (agency) and the housing owner. A form has been provided for this purpose on the Grantees Only website and in this handbook. The grantee may make rental assistance payments only to an owner with whom the grantee has entered into a rental assistance agreement. The rental assistance agreement must set forth the terms under which rental assistance will be provided, including the requirements that apply under this section. The rental assistance agreement must provide that, during the term of the agreement, the owner must give the grantee a copy of any notice to the program participant to vacate the housing unit, or any complaint used under state or local law to commence an eviction action against the program participant. The rental assistance agreement must contain the same payment due date, grace period, and late payment penalty requirements as the program participant's lease. The rental assistance agreement with the owner must terminate and no further rental assistance payments under that agreement may be made if: 1. The program participant moves out of the housing unit for which the program participant has a lease; 2. The lease terminates and is not renewed; or 3. The program participant becomes ineligible to receive ESG rental assistance. The rental assistance agreement is in the Forms section of this guidebook and on the ESG Grantees Only webpage should be used. Late Payments The grantee must make timely payments to each owner in accordance with the rental assistance agreement. The DCA Grantee is solely responsible for paying late payment penalties that it incurs with non-ESG funds. Leases Each program participant receiving rental assistance must have a legally binding, written lease for the rental unit, unless the assistance is solely for rental arrears. The lease must be between the owner and the program participant. Where the assistance is solely for rental arrears, an oral agreement may be accepted in place of a written lease, if the agreement gives the program participant an enforceable leasehold interest under state law and the agreement and rent owed are sufficiently documented by the owner's financial records, rent ledgers, or canceled checks. ESG Guidelines v2, August 2013 Page 20 Rent Reasonableness and Fair Market Rent (FMR) Rental assistance cannot be provided for a housing unit unless the total rent for the unit does not exceed the fair market rent established by HUD, as provided under 24 CFR 982.503, and complies with HUD's standard of rent reasonableness, as established under 24 CFR 982.507. These rent restrictions are intended to make sure that program participants can remain in their housing after their ESG assistance ends. Rent reasonableness and FMR requirements do not apply when a program participant receives only financial assistance or services under Housing Stabilization and Relocation Services. This includes rental application fees, security deposits, an initial payment of "last month's rent," utility payments/deposits, and/or moving costs, housing search and placement, housing stability case management, landlord-tenant mediation, legal services, and credit repair. Rent Reasonableness The rent charged for a unit must be reasonable in relation to rents currently being charged for comparable units in the private unassisted market and must not be in excess of rents currently being charged by the owner for comparable unassisted units. Rent reasonableness can be determined by accessing www.georgiahousingsearch.org. Other local resources may be used to obtain information, e.g.: market surveys, classified ads, information from real estate agents. Supporting documentation includes a copy of the signed and dated Rent Reasonableness chart. The proposed unit must be compared to three (3) other units. Fair Market Rent (FMR) FMRs are gross rent estimates. The U.S. Department of Housing and Urban Development (HUD) annually estimates FMRs for 530 metropolitan areas and 2,045 nonmetropolitan county FMR areas. HUD sets FMRs to assure that a sufficient supply of rental housing is available to program participants. By law HUD is required to publish new FMRs at the start of the federal fiscal year, on October 1. Fair Market Rents are updated by HUD every year and can be found online at: http://www.huduser.org/portal/datasets/fmr.html When calculating the FMR, be sure to include the utility allowance provided by your local housing authority. The monthly utility allowance is added only for those utilities that the tenant pays for separately from the rent (i.e. if range and refrigerator are included in the rental price, the monthly allowance for those items would not be used in the calculation). The utility allowance does not include telephone, cable or satellite television service, and internet service. If all utilities are included in the rent, there is no utility allowance. When calculating the whether or not the "Contract Rent" (or the amount payable to the landlord) is at or below the FMR, be sure to add the contract rent to the utility allowance provided by the appropriate housing authority. The monthly utility allowance is calculated only for those utilities that the tenant pays for separately from the rent (i.e. if range and refrigerator are included in the rental price, the monthly allowance for those items would not be used in the calculation). The utility allowance does not include telephone, cable or satellite television service, and internet service. If all utilities are included in the rent, there is no utility allowance. To determine whether or not the proposed unit meets the FMR requirements use this formula: ESG Guidelines v2, August 2013 Page 21 FMR Utility costs included in rent per PHA schedule = Maximum contract allowed rent Example: FMR for 2 BR unit in Effingham County = $870 The proposed 2 bedroom apartment unit in Effingham County has a Contract Rent of $650 The DCA (the HCVP in Effingham is administered by DCA) Utility Allowance for "heating, cooking, hot water, electricity and air conditioning" totals = $176 It should be noted that this unit does not have a "heat pump" and the contract rent payable to the landlord includes "water, sewer, trash service, a range and a refrigerator." Otherwise, the Utility Allowance would be higher. So, the math works like this: $650 + $176 = $826. Since $870 is the maximum rent allowed, the proposed unit meets the FMR standard and can be reviewed for rent reasonableness. The Housing Choice Voucher Program "HCVP" (a/k/a "Section 8") is administered by seventeen (17) different housing authorities in Georgia. Sixteen (16) local housing authorities administer programs and have utility schedules for use in those jurisdictions. DCA operates a balance of state HCVP and publishes a utility schedule for its jurisdiction. Complete information on HCVP implementation in Georgia may be found on the DCA website at: http://www.dca.ga.gov/housing/RentalAssistance/programs/admin_hcvp.asp. Rental assistance programs in the Balance of State Continuum of Care should use the utility allowance published on the DCA website here: http://www.dca.ga.gov/housing/RentalAssistance/programs/downloads/2013%20Utility%20Allowances.pdf Lead Based Paint Disclosure and Remediation Childhood lead poisoning is a major environmental health problem in the United States, especially for low-income families in poor living conditions. If not detected early, children with high levels of lead in their bodies can suffer from damage to the brain and nervous system, behavioral and learning problems (such as hyperactivity), slowed growth, hearing problems, and headaches. Grantees that receive funds for Emergency Shelter, Homeless Prevention and Rapid Re-Housing MUST comply with the Lead-Based Paint Poisoning Prevention Act (42 U.S.C. 48214846), the Residential Lead-Based Paint Hazard Reduction Act of 1992 (42 U.S.C. 48514856), and implementing regulations in 24 CFR part 35, subparts A, B, H, J, K, M, and R. Most emergency shelters are exempt, because they fall under the definition of zero-bedroom dwellings, which are exempt under the Title X statute. If the shelter does not qualify for the zero-bedroom exemption, it is covered by the regulation. A zero-bedroom dwelling is defined in section 35.110 as "any residential dwelling in which the living areas are not separated from the sleeping area. The term includes efficiencies, studio apartments, dormitory or single room occupancy housing, military barracks, and rentals of individual rooms in residential dwellings." The term "single room occupancy housing" is defined as "housing consisting of zero-bedroom dwelling units that may contain food preparation or sanitary facilities or both." Group homes are exempt if they consist of "rentals of individual rooms in residential dwellings." If you provide funds for a shelter with units having one or more bedrooms, and that receive assistance for more than 100 days, it is required that you adopt and implement a policy that assures that the child-occupied ESG Guidelines v2, August 2013 Page 22 spaces will be lead safe. If you provide funds for a shelter with zero-bedroom units, or a shelter receiving assistance for up to, but not more than, 100 days, the units are exempt from the regulation, but HUD recommends that you adopt and implement a policy that assures that the child-occupied spaces will be lead safe, when the units are occupied by children of less than 6 years of age. For homeless prevention and rapid re-housing the rule is that a lead-based paint visual assessment must be completed for all units that meet the three following conditions: o The household living in the unit is being assisted with ESG financial assistance (rent assistance, utilities assistance, utility/security deposits, or arrears) o The unit was constructed prior to 1978 o A child under the age of six, or a woman who could become pregnant is or may be living in the unit If any property meets all of the above three conditions, you should carry out appropriate measures per the guidance online on the ESG Grantees Only web page. Emergency Shelter Sub-grantees Grantees should refer to 24 CFR Part 35, subpart K of the implementing regulations for guidance on appropriate steps to carry out. Emergency Shelter Grantees MUST contact DCA immediately if they suspect that they are not in full compliance with these regulations. Homeless Prevention and Rapid Re-Housing Activities Please refer to the Lead Based Paint Screening Worksheet located within this handbook. Please contact your local Government office or DCA if you require further assistance. Use with Other Subsidies ESG financial assistance for rents and utilities cannot be provided to a program participant who is receiving the same type of assistance through other public sources or to a program participant who has been provided with replacement housing payments under the URA, during the period of time covered by Uniform Relocation Act (URA) payments. Except for a one-time payment of rental arrears on the tenant's portion of the rental payment, rental assistance cannot be provided to a program participant who is receiving tenant-based rental assistance, or living in a housing unit receiving project-based rental assistance or operating assistance, through other public sources. Rental assistance may not be provided to a program participant who has been provided with replacement housing payments under the URA during the period of time covered by the URA payments. IX. HOMELESS MANAGEMENT INFORMATION SYSTEM (HMIS) DCA sets specific HMIS policies and procedures for the ESG program. The information can be found and may be updated occasionally on the ESG Grantees Only webpage of the DCA website. Additional HMIS guidance and materials can also be found on the webpage. a. Reporting Requirements ESG Guidelines v2, August 2013 Page 23 HUD is expected to release new data standards and reporting requirements for ESG within the current grant year. We cannot predict when this will occur, but are taking measures to ensure that data collected in HMIS will meet new requirements as best as we can anticipate. In the meantime, the HUD APR Report in HMIS will be used as the benchmark for data collection by DCA and grantees. End of year data will be taken directly from HMIS. Domestic violence service providers are required to submit a HUD format Annual Performance Report (APR) taken directly from ALICE via email to the ESG Coordinator at the end of the State Fiscal Year. The report should be run for the entirety of the State Fiscal Year; from July 1, 2013 through June 30, 2014. b. Data Quality Checks and the Reimbursement Process DCA staff will run data quality reports when reimbursement requests are submitted by ESG grantees. Data quality reports will measure the levels of missing data and answers of "Don't Know/Refused" for Universal Data Elements and Program Data Elements, among other quality measures. HMIS data reviewed will include, but is not limited to, completion of client income and benefits at program enrollment and discharge, special needs, and bed utilization data. Reimbursement requests for programs with unacceptable levels of data quality will be held by DCA until the DCA grantee informs the ESG Program Coordinator that data has been cleaned. At that time another data quality report will be run to measure levels of improvement. Reports will examine all client data from the beginning of the grant through the date the reimbursement request is received. A sample data quality report is available in the back of this guidebook. Please contact Jason Rodriguez or April Lockett for assistance understanding the report. You may contact April Lockett for assistance with data cleaning. c. Data Quality Compliance for Domestic Violence (DV) Service Providers ESG grantees who are domestic violence service providers and are providing ESG assistance to victims of domestic violence should not use HMIS, but should use ALICE to record client data. DV providers will submit the HUD APR to DCA when requesting reimbursement. Each report submitted should have a start date of July 1, 2013 and an end date of the last date of service included in the request. DV providers are expected to comply with the same Data Quality standards as agencies who are not serving victims of domestic violence. d. Follow-Up Contact After Program Discharge ESG grantees (with the exception of Outreach and Project Homeless Connect)are expected to make follow-up contacts with program participants after program discharge at intervals designated in their contracts in order to determine current housing status. Grantees will set up Program Follow-ups attached to each ESG program in HMIS before enrolling participants into their programs in order to track follow-up outcomes. X. CoC COORDINATION WITH ESG To ensure coordination of resources among grantees DCA utilizes the following approaches and procedures: 1. Common intake form based on HMIS intake-- Grantees of DCA ESG funds are required to use a common intake form which is available on DCA's ESG webpage. If grantees have additional information that they would like to collect, they can make addendums to the form, but all data on this form must be captured. ESG Guidelines v2, August 2013 Page 24 2. Near-statewide HMIS prevents duplicative efforts All grantees will be required to use HMIS per the Interim Rule. This helps avoid duplication of services and HMIS client data, and provides an opportunity to document homelessness or risk of homelessness. Recipients of DCA ESG funds are required to use the Pathways COMPASS HMIS to enter relevant data. 3. Required Barriers to Housing Stability Assessment a common assessment is recorded and stored in HMIS at program enrollment/system entry by all ESG grantees. 4. Required electronic referrals providers will be required to record referrals in HMIS. 5. Online access to mainstream benefit application tool ESG grantees will use the Statewide COMPASS system to evaluate participant eligibility for mainstream benefits such as TANF, SNAP, etc. (https://compass.ga.gov/selfservice/) Centralized or Coordinated Assessment The Georgia Balance of State CoC will be expected to develop and implement a centralized or coordinated assessment system. The ESG regulation requires all grantees to participate in the system to initially assess the eligibility and needs of each household seeking homeless assistance. ESG grantees will be expected to implement this provision after their respective CoC has devised and implemented such an assessment system. A centralized or coordinated assessment system covers the geographic area, is easily accessed by individuals and families seeking housing or services, is well advertised, and includes a comprehensive and standardized assessment tool. The assessment system may vary from community to community based on individual communities' needs. The CoC will develop a common assessment tool for use throughout the community. HUD believes that centralized or coordinated assessment systems are important in ensuring the success of homeless assistance and homeless prevention programs in communities. In particular, such assessment systems help communities systematically assess the needs of program participants and effectively match each individual or family with the most appropriate resources available to address that individual or family's particular needs. DCA's Balance of State CoC will begin devising a system that will incorporate the above elements and consult with its stakeholders to ensure that the system aligns with their other obligations. XI. PERFORMANCE STANDARDS AND MEASURES The Georgia Department of Community Affairs (DCA) has established the primary goal of reducing the number of unsheltered homeless individuals and families in the Balance of State ESG entitlement. The information contained below outlines goals, strategies and performance measures to be utilized for all ESG grantees. Overall Goals 1. Reduce the number of unsheltered individuals and families, as established in the Homeless Point in Time Count, within the BoS ESG Entitlement by 1% each year. This goal will be achieved by placing emphasis on high utilization of emergency shelters and transitional housing beds. This will be measured in HMIS. a) Reduce length of stay for clients in emergency shelters and transitional housing programs in order to provide services to additional households. Length of stay should generally be no longer than 90 days for shelters and 1 year for Transitional Housing. This will be measured in HMIS. b) Increase placements into permanent housing for homeless individuals and families from Emergency Shelter and Transitional housing by 5% each year. This will be measured in HMIS. ESG Guidelines v2, August 2013 Page 25 2. Prevent individuals and families from becoming homeless either unsheltered or sheltered, by 3% each year. Follow-up contacts will be made at 3 months and 6 months post discharge. This will be measured in HMIS. 3. Increase the percentage of individuals and families remaining in permanent housing for 3 months by 2% each year. This goal will be achieved by increasing income or access to mainstream benefits for program participants while in the ESG program. This will be measured in HMIS. ESG programs with different eligible activities will require different assessment standards. A baseline for certain criteria, such as increase in cash and non-cash incomes over program enrollment, must first be established to measure performance. For categories with established baselines, standards are enumerated. DCA will review all available data annually to evaluate performance and adjust standards as appropriate. *For each Emergency Shelter program, performance will be measured based on the following standards: 1. An overall bed utilization rate of 80%. 2. The average length of stay of the households served should be no longer than 60 days for those exiting to permanent destinations. 3. An increase in the percentage of discharged households that secure permanent housing at exit by 5% each year. 4. An increase in the percentage of households that increase cash and non-cash income during program enrollment. For each Transitional Housing program, performance will be measured based on the following standards: 1. An overall bed utilization rate of 80%. 2. The average length of stay for households served should generally be no longer than nine months for those exiting to permanent housing. 3. An increase in the percentage of discharged households that secured permanent housing at exit by 5% each year. 4. An increase in the percentage of households that increase cash and non-cash income during program enrollment. For each Rapid Re-Housing program, performance will be measured based on the following standards: 1. An increase in the percentage of discharged households that secured permanent housing at program exit by 2% each year. 2. An increase in the percentage of discharged households permanently housed three months after exit. 3. An increase in the percentage of households that increase cash and non-cash income during program enrollment. For each Homeless Prevention program, performance will be measured based on the following standards: 1. An increase in the percentage of discharged households that maintained permanent housing at program exit by 3% each year. 2. An increase in the percentage of discharged households permanently housed three months after exit. 3. An increase in the percentage of households that increase cash and non-cash income during program enrollment. For each Street Outreach program, performance will be measured based on the following standards: 1. An increase in the number of contacts with unduplicated individuals made during outreach. ESG Guidelines v2, August 2013 Page 26 2. An increase in the percentage of households that access emergency shelter or transitional housing. 3. An increase in the percentage of discharged households that access permanent housing. 4. An increase in the percentage of households that increase cash and non-cash income during program enrollment. *Shelters serving the chronically homeless or chemically dependent clients, or shelters with minimal barriers to entry may be held to different standards than other emergency shelters. The same applies for transitional housing and rapid re-housing programs. XII. REQUIRED WRITTEN STANDARDS-POLICIES AND PROCEDURES DCA requires that each grantee establish and consistently apply policies and procedures for each ESG program administered by the grantee. All written standards require approval from DCA prior to implementation. At a minimum these written standards must include: Required for ALL PROGRAMS: 1. Standard policies and procedures for evaluating eligibility. 2. Policies and procedures for coordination among emergency shelter providers, essential services providers, homelessness prevention, and rapid rehousing assistance providers; other homeless assistance providers; and mainstream service and housing providers (see 576.400(b) and (c) for a list of programs with which ESG-funded activities must be coordinated and Integrated to the maximum extent practicable); 3. Participation in HMIS or ALICE. The grantee must ensure that data on all persons served and all activities assisted under ESG are entered into the Pathways Compass HMIS. If the grantee is a victim service provider, it may use ALICE, to collect client- level data over time (i.e., longitudinal data) and generates unduplicated aggregate reports based on the data. Additional standards for STREET OUTREACH: 1. Standards for targeting and providing essential services related to street outreach. Additional standards for EMERGENCY SHELTER: 1. Policies and procedures for admission, diversion, referral, and discharge by emergency shelters, including standards regarding length of stay, if any, and safeguards to meet the safety and shelter needs of special populations, [e.g., victims of domestic violence, dating violence, sexual assault, and stalking; and individuals and families who have the highest barriers to housing and are likely to be homeless the longest] 2. Policies and procedures for assessing, prioritizing, and reassessing needs for essential services related to emergency shelter Additional standards for PREVENTION and RAPID RE-HOUSING: 1. Policies and procedures for determining and prioritizing homelessness prevention and rapid re-housing assistance; ESG Guidelines v2, August 2013 Page 27 2. Standards for determining what percentage or amount of rent and utilities costs, if any, each program participant must pay while receiving homelessness prevention or rapid re-housing assistance; 3. Standards for determining how long a particular program participant will be provided with rental assistance and whether and how the amount of that assistance will be adjusted over time, if at all 4. Standards for determining the type, amount, and duration of housing stabilization and/or relocation services to provide, including the limits, if any, on the homelessness prevention or rapid re-housing assistance that each program participant may receive, such as the maximum amount of assistance, maximum number of months in the program; or the maximum number of times the program participant may receive assistance. XIII. TERMINATION, COMPLAINTS, APPEALS AND CONFIDENTIALITY POLICIES As part of each program's policies and procedures, grantees must develop policies regarding termination of assistance to participants, complaints, appeals, and confidentiality procedures. Sample policies are in the Forms section of this manual. Terminating Assistance If a program participant violates program requirements, the grantee may terminate the assistance in accordance with a formal process established by the grantee, and approved by the recipient, that recognizes the rights of individuals affected. The grantee must exercise judgment and examine all extenuating circumstances in determining when violations warrant termination so that a program participant's assistance is terminated only in the most severe cases. Prevention and Rapid Re-Housing Terminations To terminate rental assistance or housing relocation and stabilization services to a program participant, the required formal process, at a minimum, must consist of: 1. Written notice to the program participant containing a clear statement of the reasons for termination; 2. A review of the decision, in which the program participant is given the opportunity to present written or oral objections before a person other than the person (or a subordinate of that person) who made or approved the termination decision; AND 3. Prompt written notice of the final decision to the program participant. Ability to Provide Further Assistance Termination does not bar the grantee from providing further assistance at a later date to the same family or individual. XIV. DCA EDUCATION POLICY All grantees of ESG funding are expected to comply with the Georgia Balance of State Education Policy. Introduction As part of their work, Homeless Providers are required to establish homeless clients within their community and encourage access to mainstream agencies and organizations. Their long-term goal should be to maximize options for each household allowing them to maintain independence. ESG Guidelines v2, August 2013 Page 28 For homeless families, working with providers within the Balance of State (BoS) Continuum of Care (CoC), establishing close connections to the local education establishments within the community is a priority. This policy sets out the following premises: Agencies should work with education providers to identify homeless families at the earliest possible opportunity, and ensuring that homeless families are aware of their rights and responsibilities under legislation. Agencies should consider homeless families' education priorities when placing a family in any form of accommodation. The family should be placed as close to their place of education to avoid disruption. Agencies should ensure that they are establishing policies that are consistent with their legal obligations to homeless families. An agency must have a member of staff who is designated to be responsible for ensuring that all children access their appropriate education service, either by being enrolled in school or accessing an early education program within the community. Liaison with Education Providers The BoS CoC works on a Continuum level to ensure close links with the Education Liaison office. They work closely as part of the State Interagency Homeless Coordination Council. On a local level, the Continuum requires that each agency receiving a Department of Community Affairs Grant liaises with their local education provider to ensure that the schools and other community agencies are aware of the resources available to homeless families. Agencies should also ensure that local education providers are invited to the local Homeless Coalition meetings. Family Choice As a Continuum, the DCA will modify the Housing Support Standards to reflect the greater priority of education in its next review. Within the Continuum, agencies should ensure that their assessment covers families' education needs and issues, and any impact that changing schools may have. This particularly concerns the placement of families close to the school any child may be attending. The case management plan must include any needs the assessment has identified, goals to eliminate any challenges and issues, and document any progress made towards achieving the goals. Agencies should make reasonable allowances to ensure that families are able to access all education services such as those that take place in the evenings, such as After School Programs. Agency Obligations Agencies need to ensure that any agency protocols or policies do not infringe on the rights of homeless families. This includes a reasonable choice in deciding the school or community education program that children should be enrolled in, and making reasonable accommodations in allowing families to access programs either before or after school. Agencies should not replace schooling for homeless families with their own programs. Any programs an agency provides should be supplemental in nature. Under new legislation, it will not be possible to discriminate against families with older children, particularly boys. Agencies will be obliged to accept all families, not just the ones with younger children. Agency Representative ESG Guidelines v2, August 2013 Page 29 Agencies will need to ensure that there is a person who has taken on the responsibility of ensuring that all homeless families understand the implications of this policy, and their decision making rights under it. This must be a "named" person, one who will be able to meet and discuss the issues with homeless families on a regular basis. This person should maintain regular contact with local school liaison officers, and other community education representatives to ensure that the agency can offer a balanced, immediate service to homeless families. XV. DOCUMENTING PERSONS WITH DISABILITIES Person with disabilities means a household composed of one or more persons at least one of whom is an adult who has a disability. (1) A person shall be considered to have a disability if he or she has a disability that: (i) Is expected to be long-continuing or of indefinite duration; (ii) Substantially impedes the individual's ability to live independently; (iii) Could be improved by the provision of more suitable housing conditions; and (iv) Is a physical, mental, or emotional impairment, including impairment caused by alcohol or drug abuse, posttraumatic stress disorder, or brain injury. (2) A person will also be considered to have a disability if he or she has a developmental disability, as defined in this section. (3) A person will also be considered to have a disability if he or she has acquired immunodeficiency syndrome (AIDS) or any conditions arising from the etiologic agent for acquired immunodeficiency syndrome, including infection with the human immunodeficiency virus (HIV). (4) Notwithstanding the preceding provisions of this definition, the term person with disabilities includes, except in the case of the SRO component, two or more persons with disabilities living together, one or more such persons living with another person who is determined to be important to their care or well-being, and the surviving member or members of any household described in the first sentence of this definition who were living, in a unit assisted under this part, with the deceased member of the household at the time of his or her death. (In any event, with respect to the surviving member or members of a household, the right to rental assistance under this part will terminate at the end of the grant period under which the deceased member was a participant.) Developmental disability means, as defined in section 102 of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15002): (1) A severe, chronic disability of an individual that-- (i) Is attributable to a mental or physical impairment or combination of mental and physical impairments (ii) Is manifested before the individual attains age 22 (iii) Is likely to continue indefinitely (iv) Results in substantial functional limitations in three or more of the following areas of major life activity: (A) Self-care (B) Receptive and expressive language (C) Learning ESG Guidelines v2, August 2013 Page 30 (D) Mobility (E) Self-direction (F) Capacity for independent living (G) Economic self-sufficiency AND (v) Reflects the individual's need for a combination and sequence of special, interdisciplinary, or generic services, individualized supports, or other forms of assistance that are of lifelong or extended duration and are individually planned and coordinated. (2) An individual from birth to age 9, inclusive, who has a substantial developmental delay or specific congenital or acquired condition, may be considered to have a developmental disability without meeting three or more of the criteria described in paragraphs (1)(i) through (v) of the definition of ``developmental disability'' in this section if the individual, without services and supports, has a high probability of meeting those criteria later in life. Written documentation of disability status includes: 1. Written verification from a professional who is licensed by the state to diagnose and treat that condition, that the disability is expected to be long-continuing or of indefinite duration and that the disability substantially impedes the individual's ability to live independently; AND 2. written verification from the Social Security Administration, or the receipt of a disability check (e.g., Social Security Disability Insurance check or Veteran Disability Compensation). Information on disability status should be obtained in the course of client assessment once the individual is admitted to a project, unless having a disability is an eligibility requirement for entry into the project. Where disability is an eligibility requirement, an intake staff-recorded observation of disability may be used to document disability status as long as the disability is confirmed by the aforementioned evidence within 45 days of the application for assistance. XVI. FAITH BASED ACTIVITIES (a) Organizations that are religious or faith-based are eligible, on the same basis as any other organization, to receive ESG funds. Neither the Federal Government nor a State or local government receiving funds under ESG shall discriminate against an organization on the basis of the organization's religious character or affiliation. (b) Organizations that are directly funded under the ESG program may not engage in inherently religious activities, such as worship, religious instruction, or proselytization as part of the programs or services funded under ESG. If an organization conducts these activities, the activities must be offered separately, in time or location, from the programs or services funded under ESG, and participation must be voluntary for program participants. (c) Any religious organization that receives ESG funds retains its independence from Federal, State, and local governments, and may continue to carry out its mission, including the definition, practice, and expression of its religious beliefs, provided that the religious organization does not use direct ESG funds to support any inherently religious activities, such as worship, religious instruction, or proselytization. Among other things, faith-based organizations may use space in their facilities to provide ESG-funded services, without removing religious art, icons, scriptures, or other religious symbols. In addition, an ESG-funded religious organization retains its authority over its internal governance, and the organization may retain religious terms in its ESG Guidelines v2, August 2013 Page 31 organization's name, select its board members on a religious basis, and include religious references in its organization's mission statements and other governing documents. (d) An organization that receives ESG funds shall not, in providing ESG assistance, discriminate against a program participant or prospective program participant on the basis of religion or religious belief. (e) ESG funds may not be used for the rehabilitation of structures to the extent that those structures are used for inherently religious activities. ESG funds may be used for the rehabilitation of structures only to the extent that those structures are used for conducting eligible activities under the ESG program. Where a structure is used for both eligible and inherently religious activities, ESG funds may not exceed the cost of those portions of the rehabilitation that are attributable to eligible activities in accordance with the cost accounting requirements applicable to ESG funds. Sanctuaries, chapels, or other rooms that an ESG-funded religious congregation uses as its principal place of worship, however, are ineligible for funded improvements under the program. Disposition of real property after the term of the grant, or any change in use of the property during the term of the grant, is subject to government-wide regulations governing real property disposition (see 24 CFR parts 84 and 85). (f) If the recipient or a grantee that is a local government voluntarily contributes its own funds to supplement federally funded activities, the recipient or grantee has the option to segregate the Federal funds or commingle them. However, if the funds are commingled, this section applies to all of the commingled funds. ESG Guidelines v2, August 2013 Page 32 Emergency Solutions Grant 2013 Agency:___________________________ Staff Name:_______________________ Date: _____/_____/__________ County: ______________________ CLIENT INTAKE FORM Last Name: _______________________________ First Name: ________________________ Middle Initial: ____ Social Security Number: ______/_____/______ Pathways Client Key: ____________ Street Address: ______________________________________ City: __________________ State: ______ Zip Code: __________ Date of Birth: _____/____/______ Chronically Homeless: ( ) Y ( ) N Sex: ( ) Male ( ) Female Ethnicity: ( ) Hispanic ( ) Non-Hispanic Race: ( ) Asian ( ) Black/African American ( ) American-Indian/Alaskan ( ) White ( ) Pacific Islander ( ) Other Last Permanent Address (Last place resided for 90 or more days) Street Address: ______________________________________ City: __________________ State: ______ Zip Code: __________ Housing Status: ( ) Literally homeless ( ) Housed and at imminent risk of losing housing ( ) Housed and at-risk of losing housing ( ) Stably housed Last Night's Residence: ( ) Emergency shelter, including hotel or motel paid for with emergency shelter voucher ( ) Transitional housing for homeless persons (including homeless youth) ( ) Permanent housing for formerly homeless persons (such as SHP, S+C, or SRO Mod Rehab) ( ) Psychiatric hospital or other psychiatric facility ( ) Substance abuse treatment facility or detox center ( ) Hospital (non-psychiatric) ( ) Jail, prison or juvenile detention facility ( ) Rental by client, no housing subsidy ( ) Owned by client, no housing subsidy ( ) Staying or living in a family member's room, apartment or house ( ) Staying or living in a friend's room, apartment or house ( ) Hotel or motel paid for without emergency shelter voucher ( ) Foster care home or foster care group home ( ) Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station/airport or anywhere outside); inclusive of "non-housing service site (outreach programs only)" ( ) Other ( ) Safe Haven ( ) Rental by client, with VASH housing subsidy ( ) Rental by client, with other (non VASH) housing subsidy ( ) Owned by client, with housing subsidy 1 Emergency Solutions Grant 2013 Length of Stay (in last night's residence): (Check One) ( ) one week or less ( ) more than one week, but less than one month ( ) one to three months ( ) more than three months, but less than a year ( ) one year or longer Family Type: (Check One) ( ) Single/Unaccompanied Female ( ) Single/Unaccompanied Male ( ) Female w/ children ( ) Male w/ children ( ) Couple w/o children ( ) Couple w/ children Veteran: ( )Y ( )N Domestic Violence: ( )Y ( )N Disabling Condition: ( )Y ( )N Authorization ( )Y ( )N Special Needs: Check ONE answer for each criterion Substance abuse (No) (Alcohol abuse) (Don't know) (Refused) (Drug abuse) (Both alcohol and drug abuse) Physical disability (No) (Yes) (Don't know) (Refused) Mental illness (No) (Yes) (Don't know) (Refused) Illiterate or marginally literate (No) (Yes) (Don't know) (Refused) HIV/AIDS and related diseases (No) (Yes) (Don't know) (Refused) Domestic violence (No) (Yes) (Don't know) (Refused) Developmental disability (No) (Yes) (Don't know) (Refused) Chronic Health Condition (No) (Yes) (Don't know) (Refused) 2 Emergency Solutions Grant 2013 Income Information Household Financial Resources: Income received from any source in past 30 days? ( ) No ( ) Yes ( ) Don't Know ( ) Refused Income Sources and Amount No/Yes Amount Date Started Whose Income? ( ) Earned Income: ( ) Unemployment Insurance: ( ) Supplemental Insurance Security (SSI) ( ) Social Security Disability Income (SSDI) ( ) Veteran Disability Payment ( ) Private Disability Insurance ( ) Workers Comp ( ) Temporary Assistance for Needy Families ( ) General Assistance ( ) Retirement Income from SS ( ) Veteran's Pension ( ) Pension from former job ( ) Child Support ( ) Alimony or other special support ( ) Other source ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes ( ) No ( ) Yes __________ ____/____/____ __________ __________ ____/____/____ __________ __________ ____/____/____ __________ ___________ ____/____/____ __________ ___________ ____/____/____ __________ ___________ ____/____/____ __________ ___________ ____/____/____ __________ ___________ ____/____/____ __________ ___________ ____/____/____ __________ ___________ ____/____/____ __________ ___________ ____/____/____ __________ ___________ ____/____/____ __________ ___________ ____/____/____ __________ ___________ ____/____/____ __________ ___________ ____/____/_____ __________ Total Monthly Income ________________ Non-Cash Benefits Non-Cash Benefits received from any source in past 30 days: ( ) No ( ) Yes ( ) Don't Know ( ) Refused Source of Non-Cash Benefit Receiving Benefit Date Started Whose Income? Supplemental Nutrition Assistance Program (SNAP) ( ) No ( ) Yes ____/____/_____ __________ Medicaid Health Insurance Program ( ) No ( ) Yes ____/____/_____ __________ Medicare Health Insurance ( ) No ( ) Yes ____/____/_____ __________ State Children's Health Insurance ( ) No ( ) Yes ____/____/_____ __________ Special Supplemental Nutrition for Women, Infants And Children ( ) No ( ) Yes ____/____/_____ __________ Veterans Administration (VA) Medical Services ( ) No ( ) Yes ____/____/_____ __________ TANF Child Care Services ( ) No ( ) Yes ____/____/_____ __________ TANF Transportation ( ) No ( ) Yes ____/____/_____ __________ Other TANF funded services ( ) No ( ) Yes ____/____/_____ __________ Section 8, public housing, or other ongoing rental assistance( ) No ( ) Yes _____/____/_____ __________ Other Source ( ) No ( ) Yes ____/____/_____ __________ Temporary Rental Assistance ( ) No ( ) Yes ____/____/_____ __________ Don't Know ( ) No ( ) Yes ____/____/_____ __________ Refused ( ) No ( ) Yes ____/____/_____ __________ Total Monthly Benefits _ ________________ 3 Emergency Solutions Grant 2013 *HOUSEHOLD MEMBERS: Record income , benefit information AND special needs in HMIS for EACH member of the household. Household Members Information (1) Relationship to Head of Household: __________________________ Last Name: __________________________ First Name: ____________________ Middle Initial :____ Date of Birth: ___/___/_____ Sex: ( ) Male ( ) Female Ethnicity: ( ) Hispanic ( ) Non-Hispanic Race: _______________ Veteran: ( )Y ( )N Disabled: ( )Y ( )N Last Permanent Address: mark one: (Same as head of household) (Different from head of household) (If different from Head of Household list below) Street Address: ______________________________________ City: __________________ State: ______ Zip Code: __________ If this is a minor child, do you have legal custody or guardianship of him/her? ( ) Yes ( ) No [Documentation will be requested.] (2) Relationship to Head of Household: __________________________ Last Name: __________________________ First Name: ____________________ Middle Initial :____ Date of Birth: ___/___/_____ Sex: ( ) Male ( ) Female Ethnicity: ( ) Hispanic ( ) Non-Hispanic Race: _______________ Veteran: ( )Y ( )N Disabled: ( )Y ( )N Last Permanent Address: mark one: (Same as head of household) (Different from head of household) (If different from Head of Household list below) Street Address: ______________________________________ City: __________________ State: ______ Zip Code: __________ If this is a minor child, do you have legal custody or guardianship of him/her? ( ) Yes ( ) No [Documentation will be requested.] (3) Relationship to Head of Household: __________________________ Last Name: __________________________ First Name: ____________________ Middle Initial :____ Date of Birth: ___/___/_____ Sex: ( ) Male ( ) Female Ethnicity: ( ) Hispanic ( ) Non-Hispanic Race: _______________ Veteran: ( )Y ( )N Disabled: ( )Y ( )N Last Permanent Address: mark one: (Same as head of household) (Different from head of household) (If different from Head of Household list below) Street Address: ______________________________________ City: __________________ State: ______ Zip Code: __________ If this is a minor child, do you have legal custody or guardianship of him/her? ( ) Yes ( ) No [Documentation will be requested.] (4) Relationship to Head of Household: __________________________ Last Name: __________________________ First Name: ____________________ Middle Initial :____ Date of Birth: ___/___/_____ Sex: ( ) Male ( ) Female Ethnicity: ( ) Hispanic ( ) Non-Hispanic Race: _______________ Veteran: ( )Y ( )N Disabled: ( )Y ( )N Last Permanent Address: mark one: (Same as head of household) (Different from head of household) (If different from Head of Household list below) Street Address: ______________________________________ City: __________________ State: ______ Zip Code: __________ If this is a minor child, do you have legal custody or guardianship of him/her? ( ) Yes ( ) No [Documentation will be requested.] 4 Emergency Solutions Grant 2013 (5) Relationship to Head of Household: __________________________ Last Name: __________________________ First Name: ____________________ Middle Initial :____ Date of Birth: ___/___/_____ Sex: ( ) Male ( ) Female Ethnicity: ( ) Hispanic ( ) Non-Hispanic Race: _______________ Veteran: ( )Y ( )N Disabled: ( )Y ( )N Last Permanent Address: mark one: (Same as head of household) (Different from head of household) (If different from Head of Household list below) Street Address: ______________________________________ City: __________________ State: ______ Zip Code: __________ If this is a minor child, do you have legal custody or guardianship of him/her? ( ) Yes ( ) No [Documentation will be requested.] A Barriers to Housing Stability Assessment must be completed for each HEAD of household. Program Enrollment: ESG Eligible: ___Yes ____No Date: _____________________ Program Entry Date ___/___/______ Date of Initial Certification: ___/___/______ Date(s) of Re-Certifications ___/___/______, ___/___/______, ___/___/______ 5 Emergency Solutions Grant 2013 HOMELESS CERTIFICATION ESG Applicant Name: ______________________________________________ Individual without dependent children (complete one form for each household) Household with dependent children (complete one form for each adult household member) Number of persons in the household: _________ This is to certify that the above named individual or household is currently homeless based on the check mark, other indicated information, and signature indicating their current living situation. Check only ONE BOX and ONLY complete that section. *IMPORTANT: THIRD PARTY EVIDENCE MUST BE ATTACHED TO THIS FORM IN ORDER TO CERTIFY HOMELESSNESS. Living Situation: place not meant for human habitation (e.g., cars, parks, abandoned buildings, streets/sidewalks) The person(s) named above is/are currently living in (or, if currently in hospital or other institution, was living in immediately prior to hospital/institution admission) a public or private place not designed for, or ordinarily used as a regular sleeping accommodation for human beings, including a car, park, abandoned building, bus station, airport, or camp ground. Description of current living situation: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Homeless Street Outreach/Other Program (if applicable): _____________________________________________________________ This certifying agency must be recognized by the local Continuum of Care (CoC) as an agency that has a program designed to serve persons living on the street or other places not meant for human habitation. (Examples may be street outreach workers, day shelters, soup kitchens, Health Care for the Homeless sites, etc.) Authorized Referral Agency Representative Signature: __________________________________Date: ______________________ Living Situation: Emergency Shelter DV Shelter? (check if "yes") The person(s) named above is/are currently living in (or, if currently in hospital or other institution, was living in immediately prior to hospital/institution admission) a supervised publicly or privately operated shelter as follows: Emergency Shelter Program Name: _____________________________________________________________ This emergency shelter must appear on the CoC's Housing Inventory Chart submitted as part of the most recent CoC Homeless Assistance application to HUD or otherwise be recognized by the CoC as part of the CoC inventory (e.g. newly established Emergency Shelter). Authorized Shelter Agency Representative Signature: _____________________________________Date: ______________________ Living Situation: Transitional Housing DV TH? (check if "yes") The person(s) named above is/are currently living in a transitional housing program for persons who are homeless. The persons(s) named above is/are graduating from or timing out of the transitional housing program: Transitional Housing Program Name: ____________________________________________________________ Immediately prior to entering transitional housing the person(s) named above was/were residing in: emergency shelter OR a place unfit for human habitation Authorized Transitional Housing Agency Representative Signature: ____________________________Date: ____________________ Living Situation: Market Housing The person(s) named above was/were evicted from or otherwise lost housing obtained through the private market. Landlord or other Third Party Signature: __________________________________Date: ____________________ Emergency Solutions Grant 2013 AT-RISK HOMELESS CERTIFICATION (for Homelessness Prevention) ESG Applicant Name: ______________________________________________ Address from which Applicant is being evicted: ____________________________________________________________ Individual without dependent children (complete one form for each adult in the household) Household with dependent children (complete one form for each adult in the household) Number of persons in the household: _________ This is to certify that the above named individual or household is currently at risk for homeless based on the information indicated below and signature indicating their current housing status. *IMPORTANT: THIRD PARTY EVIDENCE, INCLUDING WRITTEN STATEMENTS, [(B) and (C) below], MUST BE ATTACHED TO THIS FORM IN ORDER TO CERTIFY AT-RISK STATUS. Living Situation: Facing Eviction The person/household named above is currently living in rental housing from which he/she/they is/are being evicted. ESG assistance provided will not overlap with other federal funding sources. The individual or family: 1. Has income below 30 percent of median income for the geographic area (see income documentation form); AND 2. Lacks sufficient resources to attain housing stability. [e.g., family, friends, faith-based or other social networks immediately available] to prevent them from moving to an emergency shelter or another place described in category 1 of the homeless definition. Evidence of the second eligibility criterion (#2 above) for this Applicant is: (A) Source documents (e.g., notice of termination from employment, unemployment compensation statement, bank statement, health-care bill showing arrears, utility bill showing arrears). (B) To the extent that source documents are unobtainable, a written statement by the relevant third party (e.g., former employer, public administrator, relative) or written certification by the intake staff of the oral verification by the relevant third party that the applicant meets one or both of the criteria of the definition of ``at risk of homelessness'' or (C) If source documents and third-party verification are unobtainable, a written statement by intake staff describing the efforts taken to obtain the required evidence. The person(s) listed above meet one or more of the following risk factors: (1) Has moved frequently because of economic reasons (2) Is living in the home of another because of economic hardship (3) Has been notified in writing that their right to occupy their current housing or living situation will be terminated within 21 days after the date of application (4) Lives in a hotel or motel; "and the cost of the hotel or motel is not paid for by federal, state, or local government programs for low-income individuals or by charitable organizations'' (5) Lives in severely overcrowded housing; (in a single-room occupancy or efficiency apartment unit in which more than two persons, on average, reside or another type of housing in which there reside more than 1.5 persons per room, as defined by the U.S. Census Bureau.) (6) Is exiting a publicly funded institution; or system of care, (such as a health-care facility, mental health facility, foster care or other youth facility, or correction program or institution) (7) Otherwise lives in housing that has characteristics associated with instability and an increased risk of homelessness continued... Emergency Solutions Grant 2013 Evidence of risk factors for this Applicant is: (A) Source documents (e.g., notice of termination from employment, unemployment compensation statement, bank statement, health-care bill showing arrears, utility bill showing arrears). (B) To the extent that source documents are unobtainable, a written statement by the relevant third party (e.g., former employer, public administrator, relative) or written certification by the intake staff of the oral verification by the relevant third party or (C) If source documents and third-party verification are unobtainable, a written statement by intake staff describing the efforts taken to obtain the required evidence. Third Party Certification I certify that I have provided verification as indicated above that the ESG Applicant meets eligibility criteria and/or risk factors for being "at-risk" of homelessness. Relevant Third-Party Representative Signature: ___________________________________Date: ___________________ ESG Staff Signature: _______________________________________ Date: ______________________ Emergency Solutions Grant 2013 SELF CERTIFICATION OF HOMELESS/DOMESTIC VIOLENCE/ AT RISK ESG Applicant Name: ______________________________________________ Household without dependent children (complete one form for each adult in household) Household with dependent children (complete one form for each adult in household) Number of persons in the household: _________ This is to certify that the above named individual or household is currently homeless based on the check mark, other indicated information, and signature indicating their current living situation. Check only one: I [and my children] am/are currently homeless and living on the street (i.e. a car, park, abandoned building, bus station, airport, or camp ground). I [and my children] am/are the victim(s) of domestic violence and am/are fleeing from abuse, have not identified a subsequent residence, and lack the resources or support networks, e.g., family, friends, faith- based, or other social networks, needed to obtain housing where my/our safety would not be jeopardized. I [and my children] am/are being evicted from the housing we are presently staying in and must leave this housing within the next 14 days. I certify that I have insufficient financial resources and support networks; e.g., family, friends, faith-based or other social networks, immediately available to obtain housing or to attain housing stability without ESG assistance. I certify that the information above and any other information I have provided in applying for ESG assistance is true, accurate and complete. ESG Applicant Signature: ___________________________________ Date: ______________________ ESG Staff Certification I understand that third-party verification is the preferred method of certifying homelessness or risk for homelessness for an individual who is applying for ESG assistance. I understand self declaration is only permitted when I have attempted to but cannot obtain third party verification. Documentation of attempts made for third-party verification: _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ ESG Staff Signature: _______________________________________ Date: ______________________ Emergency Solutions Grant 2013 STAFF CERTIFICATION OF HOMELESS/DOMESTIC VIOLENCE/ AT RISK [Oral third party verification] I understand that securing third party documentation is the preferred method of certifying homelessness or risk for homelessness for an individual who is applying for ESG assistance, but cannot obtain source documents. Below I am providing details of oral third party verification of eligibility or risk factors and certifying all statements to be true, accurate and complete. Oral verification by the relevant third party was made on ______________ (date) through a conversation with _____________________________________ (Relevant Third-Party Representative) Verification of homelessness was provided: Over the phone In person Regarding _______________________________________ (ESG applicant) The following information was provided regarding the ESG applicant's homeless status, victim status and available resources: _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ I understand that obtaining third party verification of eligibility or risk factors is the preferred method of certifying eligibility for an individual who is applying for ESG assistance, but cannot meet this standard. I made the following efforts to obtain third party verification: _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ ESG Staff Signature: _______________________________________ Date: ______________________ [Staff/Intake worker observation verification] I have observed the following conditions which serve as evidence related to the applicant's housing status, victim status and available resources. Due to the following factors I certify this applicant's eligibility for ESG assistance. _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ I understand that obtaining third party verification of eligibility or risk factors is the preferred method of certifying eligibility for an individual who is applying for ESG assistance, but cannot meet this standard. I made the following efforts to obtain third party verification: _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ ESG Staff Signature: _______________________________________ Date: ______________________ Emergency Solutions Grant 2013 CERTIFICATION OF CHRONIC HOMELESSNESS This document may be used to analyze whether or not an individual or family meets the definition of chronic homelessness. Documentation must be attached to verify status. ESG Applicant Name: ______________________________________________ Household without dependent children (complete one form for each adult in household) Household with dependent children (complete one form for each adult in household) Number of persons in the household: _________ Applicant or head of household has the following disability based on the condition(s): (check all that apply) A diagnosable substance abuse disorder A serious mental illness A developmental disability A chronic physical illness or disability, including the co-occurrence of two or more of these conditions. AND Has been literally homeless: For at least 1 year or On at least four separate occasions in the last 3 years, where each occasion lasted for at least 15 days or Continuously unsheltered or Living in a shelter for past 1 year, or This is the 4th separate occurrence of this living situation in the past 3 years Time Period Time Number Beginning Period End of Days Location of Stay Total days Based on this summary, I certify that the client: is chronically homeless Documented? Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No is not chronically homeless. ESG Staff Signature: _______________________________________ Date: ______________________ Emergency Solutions Grant 2013 SELF-STATEMENT OF CHRONIC HOMELESSNESS Third-party verification of chronic homelessness is always preferred, however, this document of Self-Statement may be used when a homeless person/household applying for ESG assistance lacks the connections with service providers necessary to complete a Third Party Verification of chronic homelessness. Documentation must be attached to verify status. ESG Applicant Name: ______________________________________________ Household without dependent children (complete one form for each adult in household) Household with dependent children (complete one form for each adult in household) Number of persons in the household: _________ Applicant or head of household has the following disability based on the condition(s): (check all that apply) A diagnosable substance abuse disorder A serious mental illness A developmental disability A chronic physical illness or disability, including the co-occurrence of two or more of these conditions. AND Has been literally homeless: For at least 1 year or On at least four separate occasions in the last 3 years, where each occasion lasted for at least 15 days or Continuously unsheltered or Living in a shelter for past 1 year, or This is the 4th separate occurrence of this living situation in the past 3 years I certify that I was homeless (sleeping in a place not meant for human habitation such as living on the streets) OR living in a homeless emergency shelter during the following period(s) of time: Time Period (Beginning) Time Period Number (End) of Days Location of Stay Total days Emergency Solutions Grant 2013 What else would you like to share about your history? For example, "I cannot remember the name of the place where I was living during the fall of 2012 but I believe that it was a homeless emergency shelter. I have problems with my memory from that time due to an illness." __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________ I certify that the above information is correct. ESG Applicant Signature: ___________________________________ Date: ______________________ ESG Staff Certification I understand that third-party verification is the preferred method of certifying homelessness or risk for homelessness for an individual who is applying for ESG assistance. I understand self declaration is only permitted when I have attempted to but cannot obtain third party verification. Documentation of attempts made for third-party verification: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ ___________________________________________________________ ESG Staff Signature: _______________________________________ Date: ______________________ Emergency Solutions Grant 2013 CHRONIC HOMELESS CERTIFICATION I certify that the signed individual below, _________________________________ (Client Name) previously resided at _______________________________________ (Facility Name) For the following period(s) of time within the last three (3) years: Time Period (Beginning) Time Period Number (End) of Days Location of Stay Total days This facility is classified as one of the following types of institutions: Emergency Shelter Transitional Housing Place not meant for human habitation Permanent Supportive Housing Medical Institution Mental Health Institution Correctional Facility Substance Abuse Facility Other: ___________________________ I further certify that immediately prior to entering this facility the person named above was residing at/in: ______________________________________ Authorized Third Party Signature: ___________________________________ Date: ______________________ I hereby authorize the release of this information: ESG Applicant Signature: ___________________________________ Date: _________________________ Category 1 Literally Homeless (1) 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; (ii) Is living in a publicly or privately operated shelter designated to provide 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); or (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 CRITERIA FOR DEFINING HOMELESS Category 2 Imminent Risk of Homelessness (2) Individual or family who will imminently lose their primary nighttime residence, provided that: (i) Residence will be lost within 14 days of the 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 Category 3 Category 4 Homeless under other Federal statutes Fleeing/ Attempting to Flee DV (3) 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) Are defined as homeless under the other listed federal statutes; (ii) Have not had a lease, ownership interest, or occupancy agreement in permanent housing during the 60 days prior to the homeless assistance application; (iii) Have experienced persistent instability as measured by two moves or more during in 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 (4) Any individual or family who: (i) Is fleeing, or is attempting to flee, domestic violence; (ii) Has no other residence; and (iii) Lacks the resources or support networks to obtain other permanent housing RECDOERFIDNKIETIEPOINNGOFREHQOUIMRELEEMSESNTS (Recordkeeping requirements) Category 1 Category 1 Literally HoLimteerlaelslys Homeless Category 2 Imminent Risk of Imminent Risk of Homelessness Homelessness CCaateteggooryry33 HHoommeelelessssuunnddeerr ootthheerrFFeeddeerraall stsattaututetes CCaateteggooryry44 FleeFinlegeDinogm/ estic AtteVmiopletinncgeto Flee DV Written observation by the outreach worker; or WCerirtttiefincarteifoenrrbayl bthyeainnodtihviedruhaol uosrinhgeaodr osefrhvoicuesephrovldidseere; koirng Caesrstiisfticaantcieonstbaytinthgethinadtiv(sid)huealwoarshleivaindgoof nhothueseshtroeldetsseoerking asshseisltaenr;coerstating that (s)he was living on the streets or in sWherlitteter;n observation by the outreach worker; or Written referral by another housing or service provider; or FPorrininteddivridecuoarlsdefrxoitmingHManISinosrtiatuntoiothne--r coonme mofutnhietyfodramtasboafse evidence above and: For oindividdiuscahlsaergxeitipnagpaenrwinosrtkitourtiwonri--tteon/eooraf lthreefeforraml,soorf evidoencewarbitotveenarnecdodridscohfainrgteakpeawpeorrwkeor'ks odruae wdirlitgteenncoerto oral refeorrbatlafirnoambosoveciaelvwidoernkceer,acnadsecemrtaifnicaagteiornorboyther appropriantdeivoidffuicailatlhaattththeeiynsetxitituetdioinn,sstittauttiniognthe beginning and end dates of the time residing in the institution A court order resulting from an eviction action notifying the inAdcioviudrutaolrodrefrarmesiluylttihnagtftrhoemy amnuestvilcetaiovne;aocrtion notifying the individual or family that they must leave; or For individual and families leaving a hotel or motel--evidence tFhoart itnhdeiyvildauckaltlheeavfiinnagnacihaol treelsoorurmceostetlo--setavyid;eonrce that they lack Athdeocfiunmanecniatel dreasnodurvceersiftieodstoarya;losrtatement; and A documented and verified oral statement; and Certification that no subsequent residence has been identified; aCnedrtification that no subsequent residence has been identified; and Self-certification or other written documentation that the inSedlifv-icdeuratilfliacacktiothneofrinoatnhceirawl rreitstoeunrcdeoscaunmdesnutpaptioornt tnheactetshseary to oinbdtaivinidpuearlmlaacnketnhtehfoinuasnincigal resources and support necessary to obtain permanent housing CCeerrttifificicaattioionnbbyytthheeninodnipvriodfuitaloorrsthaetaedoorflohcoaulsgeohvoelrdnsmeeeknitntghat tahsesiisntdainvcideutahlaotr(sh)ehaedmoef thtohuesechrioteldriaseoefkhinogmaeslseisstsannecses umnedtetrhe carintoerthiaeor ffehdoemraellestsasntuetsessu; nadnedr another federal statute; and CCeerrttifificicaattioionnobfyntohPeHinidnivlaidsut a6l0odrahyesa; danodf household, and any Caevratiilfaicbalteiosnupbpyotrhtienignddoivciduumaelnotrahtieoand, tohfahto(us)sheehohlads,manodveadnythree aovramilaobrlee tsiumpepsoirntinthgedpoacsutm9e0ndtaaytiso;na,ntdhat (s)he has moved two or mDoorceumtimenetsaitniotnheofpdaissta6b0ilidtyayosr; 2anodr more barriers to Deomcupmloyemnteantiton of special needs or 2 or more barriers FFoorrvdicotmimesteircvvicioelepnrocevidperorsv:iders: ooAAnnoorraallssttaatteemmeennttbbyytthheeininddivivididuuaalloorrhheeaaddooffhhoouusseehhooldld sseeeekkininggaassssisisttaanncceewwhhicichhsmtautests:bethdeoycaurme eflneteeidngb;ythaesyelhfa- ve no scuebrsteifqicuaetniotnreosridaecnecreti;fiacnadtiothnebyylathcke rinestaokuercweso.rkSetra;toemr ent omWursittbeen doobcsuemrveantitoendbbyytaheseilnft-caekretiwficoartkieorn; or a certification by otWheritntteankerewfeorrkael rb.y a housing or service provider, social Forwnornk-evric,ttihmesheorvspicietapl roorvtidherps:olice oFoOrrnaol nst-datoemmeesntitcbvyiotlheencinedpirvoidvuidaelros:r head of household seeking oaOssriasltastnacteemtheanttthbeyythaereinfdleiveidnuga. lTohrishestaadteomf heonut sisehdoolcdusmeeknitnegd bayssaisstealnf-cceertthifaictaistidooncourmbeynttheed cbaysaewseolrfk-ceerr.tiWfichaetrioenthoer bsayftehtey ocfatsheewionrdkievrid. uWalhoerrefatmheilysaisfentoyt ojefotphaeridnidzeivdi,dtuhael oraflamily is sntaottejmeoepnatrmdiuzestdb, ethveeorirfaields;tatnedment must be verified; 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Emergency Solutions Grant 2013 VERIFICATION OF INCOME ESG Applicant Name: ______________________________________________ Instructions for Employer/Payment Source Representative: This is to certify the income received by the above named individual for purposes of participating in the ESG program. This information will be used only to determine the eligibility status and level of household benefit. Complete only the selected section below that includes an authorization to release information. Please return this form to: Name & Title: __________________________________ Address: __________________________________ Email: __________________________________ Phone: ____________________________ Fax: ____________________________ Employment Income ESG Applicant Release: I hereby authorize the release of the following employment information. ESG Applicant Signature: _______________________________ Date: ______________________ Employer representative to complete this section: The person named above is employed by ______________________________________since _______________. He/she is paid $______________ on a _____________basis and is currently working an average of _____________hours per ____________. Additional compensation please specify (if any):__________________________________________________________ Probability of continued employment: ________________________________________________________________ Authorized Employer Representative Signature: ____________________________________ Date:__________________ Name, Title: _______________________________________________________________________________________ Address and Phone: _________________________________________________________________________________ Payments and/or Benefit Income (complete one form for each distinct source of income for each adult member of household and attach supporting evidence to this form in case file) CIRCLE ONE: Social Security/SSI Pension/Retirement TANF Public Assistance Unemployment Compensation Workers Compensation Alimony Payments Foster Care Payments Child Support Payments Armed Forces Income Other (pls. specify): ___________________________________________________________ ESG Applicant Release: I hereby authorize the release of the following payment and/or benefit information. ESG Applicant Signature: _______________________________ Date: ______________________ Payment source representative to complete this section: Payments or benefits in the amount of $_______________________ are paid on a ______________________ basis. The expected duration of the payments or benefits is _____________________________. Authorized Payment Source Representative Signature: _______________________________ Date:_________________ Name, Title: ______________________________________________________________________________________ Address and Phone: _______________________________________________________________________________ Emergency Solutions Grant 2013 SELF-DECLARATION OF INCOME ESG Applicant Name: ______________________________________________ This is to certify the income status for the above named individual. Income includes but is not limited to: The full amount of gross income earned before taxes and deductions. The net income earned from the operation of a business, i.e., total revenue minus business operating expenses. This also includes any withdrawals of cash from the business or profession for your personal use. Monthly interest and dividend income credited to an applicant's bank account and available for use. The monthly payment amount received from Social Security, annuities, retirement funds, pensions, disability and other similar types of periodic payments. Any monthly payments in lieu of earnings, such as unemployment, disability compensation, SSI, SSDI, and worker's compensation. Monthly income from government agencies excluding amounts designated for shelter, and utilities, WIC, food stamps, and childcare. Alimony, child support and foster care payments received from organizations or from persons not residing in the dwelling. All basic pay, special day and allowances of a member of the Armed Forces excluding special pay for exposure to hostile fire. Check only one box and complete only that section I certify, under penalty of perjury, that I currently receive the following income: Source: _______________________________________ Amount: _____________ Frequency: _____________ Source: _______________________________________ Amount: _____________ Frequency: _____________ Source: _______________________________________ Amount: _____________ Frequency: _____________ ESG Applicant Signature: _______________________________ Date: ______________________ I certify, under penalty of perjury, that I do not have any income from any source at this time. ESG Applicant Signature: _______________________________ Date: ______________________ ESG Staff Verification *This section MUST be completed. I understand that third-party verification is the preferred method of certifying income for ESG assistance. I understand self declaration is only permitted when I have attempted to but cannot obtain third party verification. Documentation of attempt made for third-party verification: _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ ESG Staff Signature: _______________________________________ Date: ______________________ ESG PREVENTION Income Eligibility Calculation Worksheet To be eligible for ESG Prevention assistance, households must be below 30% of the Area Median Income (and meet other eligibility requirements). Grantees may use this sample worksheet to determine whether an applicant household meets the ESG income eligibility threshold. A copy of this worksheet should be kept in the ESG participant case file. Household Member Number 1 Household Member Name Age of Household Member 2 3 4 5 6 7 8 9 10 11 Total Household Members (Household size) 30% of Area Median Income (AMI) for Household Size Household Member Number/Name Sources of Household Income Earned Income (for ADULT household members only) Documented Current Income Amount Before Taxes Number of Annual Gross Payments per Income (gross Year income amount X # of payments $ - Earned Income (for ADULT household members only) $ - Earned Income (for ADULT household members only) $ - $ - Self-employment/business income $ - $ - Self-employment/business income $ - $ - Interest & Dividend Income $ - $ - Interest & Dividend Income $ - $ - Pension/Retirement Income $ - $ - Pension/Retirement Income $ - $ - Unemployment & Disability Income $ - $ - Unemployment & Disability Income $ - $ - TANF/Public Assistance $ - $ - TANF/Public Assistance $ - $ - Alimony, Child Support and Foster Care Income $ - $ - Alimony, Child Support and Foster Care Income $ - $ - Armed Forces Income $ - $ - Armed Forces Income $ - $ - Other (specify): $ - $ - Other (specify): $ - $ - Total Annual Gross Income from all Sources $ - 30% of Area Median Income for Household Size $ - Difference (If less than AMI, then household is income eligible) $ - Is the household below 30% Area Median Income? NO-Not Income Eligible ESG Rapid Re-Housing Income Eligibility Calculation Worksheet To be eligible for ESG Rapid Re-Housing assistance, households must be at or below 50% of the Area Median Income (and meet other eligibility requirements). Subrecipients may use this worksheet to determine whether an applicant household meets the ESG income eligibility threshold for rapid re-housing. A copy of this worksheet should be kept in the ESG participant case file. *This form should not be used for RRH annual re-certification, only RRH inital eligibility, 3, 6, and 9 month re-certifications. Household Member Number 1 Household Member Name Age of Household Member 2 3 4 5 6 7 8 9 10 11 Total Household Members (Household size) 50% of Area Median Income (AMI) for Household Size $ - Household Member Number/Name Sources of Household Income Earned Income (for ADULT household members only) Gross Documented Current Income Amount Number of Payments per Year Annual Gross Income (gross income amount X # of $ - Earned Income (for ADULT household members only) $ - Earned Income (for ADULT household members only) $ - $ - Self-employment/business income $ - $ - Self-employment/business income $ - Interest & Dividend Income $ - $ - Interest & Dividend Income $ - $ - Pension/Retirement Income $ - $ - Pension/Retirement Income $ - $ - Unemployment & Disability Income $ - $ - Unemployment & Disability Income $ - $ - TANF/Public Assistance $ - $ - TANF/Public Assistance $ - $ - Alimony, Child Support and Foster Care Income $ - $ - Alimony, Child Support and Foster Care Income $ - $ - Armed Forces Income $ - $ - Armed Forces Income $ - $ - Other (specify): $ - $ - Other (specify): $ - $ - Total Annual Gross Income from all Sources $ - 50% of Area Median Income for Household Size $ - Variance (If less than AMI, then household is income eligible) $ - Is the household at or below 50% Area Median Income? YES-Income Eligible Emergency Solutions Grant 2013 HOUSEHOLD RECERTIFICATION FORM Households receiving ESG Prevention and Rapid Re-Housing assistance must be recertified every 90 days. At the end of each recertification the case manager must attach the new evidence to this form demonstrating the household is still eligible for the program. It is not acceptable to reattach the evidence from previous eligibility decisions. *NOTE: Recertification criteria for rapid re-housing and prevention programs are different. Client Name:_________________________________________ Client is enrolled in: Prevention Program and must have household income below 30% AMI Rapid Re-Housing Program and must have household income at or below 50% AMI Rapid Re-Housing for one year and must have household income below 30% AMI Date of Entry Into Program:_______________________ Case manager: ________________________________ Number of Months (Including arrears) Household has received assistance:__________________ Date of this Re-Certification:__________________________ Please list the member(s) of this Household: Adult(s): 1. __________________________________ 2. __________________________________ 3. ___________________________________ 4. ___________________________________ 5. ___________________________________ Children (Under 18): 1. ___________________________________ 2. ___________________________________ 3. ___________________________________ 4. ___________________________________ 5. ___________________________________ STATUS Please update the household's current housing status AND attach the appropriate documentation: Literally Homeless (LH) Imminently losing housing (ILH) Unstably Housed and at risk of losing housing (UH) Documentation List 1. _____________________________________________ 2._____________________________________________ 3._____________________________________________ INCOME Please update the household's current income status AND attach the appropriate documentation: Household Income meets AMI requirements for program Household Income does not meet AMI requirements for program Documentation List 1.______________________________________________ 2.______________________________________________ 3.______________________________________________ Households with an income that is 30% AMI or higher are no longer eligible to receive ANY ESG SERVICES. They should be discharged from the program. Page 1 of 2 Emergency Solutions Grant 2013 RESOURCES For clients who are receiving ongoing ESG financial assistance, staff must document their inability to pay for the item BUT FOR the ESG assistance. (example: bank/saving statements, medical bills, etc). Household HAS NO other housing options, financial resources, or support networks identified. Household HAS other housing options, financial resources, or support networks identified. Documentation List 1._______________________________________________ 2._______________________________________________ 3._______________________________________________ HOUSING STABILITY GOALS Household agrees to work on the following goals to ensure a stable housing outcome: 1._________________________________________________________________________________________________ 2._________________________________________________________________________________________________ 3._________________________________________________________________________________________________ STAFF CERTIFICATION: (please check one) Household Eligible for additional services Household Ineligible If ineligible, please list community based agencies that household can access for further support. 1. ___________________________________ 2. ___________________________________ 3. ___________________________________ ESG STAFF: _________________________________ DATE: __________ *Documentation proving the statements made on this form MUST be attached. Simply filling in this form does not make the household eligible. Subsequent recertification forms and evidence should be kept behind this form in client file. Page 2 of 2 Emergency Solutions Grant 2013 Emergency Solutions Grant (ESG) Rental Assistance Agreement An ESG grant from the U. S. Dept. of Housing and Urban Development was provided to the Georgia Department of Community Affairs and sub-awarded to the following non-profit service agency: ________________________________________________. Through this agreement rental assistance is being provided to the following individual or head of household: Name of program participant: _____________________________________________ For the following address: _________________________________________________ Unit number: ____________________________ Name of apartment complex, as applicable: ________________________________________ Monthly rent for this unit is $__________. Payment is due on the _________ day of the month every month. Payments received after the _______ day of the month will be penalized with a late fee in the amount of $__________. Term of Agreement (dates) __________________________________ During the term of the agreement, the owner/landlord must give the agency named above a copy of any notice to the program participant (tenant) to vacate the housing unit, or any complaint used under state or local law to commence an eviction action against the program participant. [24 CFR 576.106(e).] Typed/Printed Name of landlord/owner: ____________________________________________ Landlord/Owner Signature: Typed/Printed Name of Agency Representative: Representative Signature: Please note: The rental assistance agreement does not take the place of the lease, or vice versa. Emergency Solutions Grant 2013 ESG Unit Inspection Requirements About this Tool The standards for housing unit inspections under the Homelessness Prevention and Rapid Re-Housing Program (ESG) are the housing habitability standards, described in Appendix C of the ESG Notice. This resource is intended to provide grantees with a summary of HUD's policies related to habitability inspections. Which units need an inspection? An on-site inspection is required anytime a program participant is receiving ESG financial assistance and moving into a new unit. (Financial assistance includes rental assistance, security deposit assistance, utility assistance, etc.) A housing unit inspection is not required for a program participant served with ESG prevention assistance in a unit in which the participant was already residing. Habitability inspections are also not required for persons receiving services only. Are habitability standards different from HUD's Housing Quality Standards? Yes. The Housing Quality Standards (HQS) used for other HUD programs are more stringent than the habitability standards outlined in the ESG Notice. Grantees are not required to use HQS, but may do so if they choose. Does a certified inspector need to conduct inspections? No. Unlike HQS inspections, which must be conducted by a certified inspector, habitability standards do not require a certified inspector to conduct on-site inspections. For example, units assisted by ESG may be inspected by: ESG program staff; Staff from or hired by an agency of the grantee's local government; or Staff from another subsidy program providing assistance to the unit and also requiring an inspection (e.g., Section 8, HOPWA TBRA), as long as they follow the minimum habitability standards required by ESG. When do inspections need to be conducted? Inspections must be conducted upon initial occupancy and then on an annual basis for the term of ESG assistance. How do I conduct on-site inspections? Use the ESG Habitability Standards Checklist (available on HUD's Homelessness Resource Exchange at http://hudhre.info) to guide you and/or other program staff conducting the on-site inspection. This checklist should be completed upon initial occupancy and on an annual basis for the term of ESG assistance. Copies of the completed checklists should be included in program participant files for documentation purposes. 1 Emergency Solutions Grant 2013 Can ESG funds be used to pay for habitability inspections? Yes, grantees may charge expenses associated with conducting habitability inspections under the Financial Assistance category. Are the habitability inspections the same as the Lead-Based Paint inspections? No. Under the Lead-Based Paint Poising Prevention Act of 1973, visual assessments for potential lead-based paint hazards must be conducted for all pre-1978 units in which a child under the age of six will be residing before financial assistance may be provided. Visual assessments must be conducted regardless of whether the program participant is receiving assistance to remain in an existing unit or moving to a new unit. Individuals can become a HUD-certified Visual Assessor by successfully completing the 20minute online training course on conducting visual assessments on HUD's website (available at: http://www.hud.gov/offices/lead/training/visualassessment/h00101.htm). Note that a HUD-certified Visual Assessor is not equivalent to a Certified Clearance Examiner, whose services may be needed if lead hazards are identified during the visual assessment. 2 Emergency Solutions Grant 2013 ESG Housing Habitability Standards Inspection Checklist About this Tool The standards for housing unit inspections under ESG are the housing habitability standards described in Appendix C of the ESG Notice. Inspections must be conducted upon initial occupancy and then on an annual basis for the term of ESG assistance. The habitability standards are different from the Housing Quality Standards (HQS) used for other HUD programs. Because the HQS criteria are more stringent than the habitability standards, a grantee could use either standard. In contrast to HQS inspections, the habitability standards do not require a certified inspector. As such, ESG program staff could conduct the inspections, using a form such as this one to document compliance. Instructions: Mark each statement as `A' for approved or `D' for deficient. The property must meet all standards in order to be approved. A copy of this checklist should be placed in the client file. Approved or Deficient Element 1. Structure and materials: The structures must be structurally sound so as not to pose any threat to the health and safety of the occupants and so as to protect the residents from hazards. 2. Access: The housing must be accessible and capable of being utilized without unauthorized use of other private properties. Structures must provide alternate means of egress in case of fire. 3. Space and security: Each resident must be afforded adequate space and security for themselves and their belongings. Each resident must be provided with an acceptable place to sleep. 4. Interior air quality: Every room or space must be provided with natural or mechanical ventilation. Structures must be free of pollutants in the air at levels that threaten the health of residents. 5. Water Supply: The water supply must be free from contamination. 6. Sanitary Facilities: Residents must have access to sufficient sanitary facilities that are in proper operating condition, may be used in privacy, and are adequate for personal cleanliness and the disposal of human waste. 7. Thermal environment: The housing must have adequate heating and/or cooling facilities in proper operating condition. 8. Illumination and electricity: The housing must have adequate natural or artificial illumination to permit normal indoor activities and to support the health and safety of residents. Sufficient electrical sources must be provided to permit use of essential electrical appliances while assuring safety from fire. 1 Emergency Solutions Grant 2013 9. Food preparation and refuse disposal: All food preparation areas must contain suitable space and equipment to store, prepare, and serve food in a sanitary manner. 10. Sanitary condition: The housing and any equipment must be maintained in sanitary condition. 11. Fire safety: Both conditions below must be met to meet this standard. a. Each unit must include at least one battery-operated or hard-wired smoke detector, in proper working condition, on each occupied level of the unit. Smoke detectors must be located, to the extent practicable, in a hallway adjacent to a bedroom. If the unit is occupied by hearing- impaired persons, smoke detectors must have an alarm system designed for hearing-impaired persons in each bedroom occupied by a hearing-impaired person. b. The public areas of all housing must be equipped with a sufficient number, but not less than one for each area, of battery-operated or hard-wired smoke detectors. Public areas include, but are not limited to, laundry rooms, day care centers, hallways, stairwells, and other common areas. CERTIFICATION STATEMENT I certify that I am not a HUD certified inspector and I have evaluated the property located at the address below to the best of my ability and find the following: Property meets all of the above standards. Property does not meet all of the above standards. Therefore, I make the following determination: Property is approved. Property is not approved. Case Name: Street Address: Apartment: City: State: Zip: Evaluator's Signature: Please Print. Name: Exec. Dir. Initial: Date: 2 Emergency Solutions Grant 2013 RENT REASONABLENESS CHECKLIST AND CERTIFICATION The rent charged for a unit must be reasonable in relation to rents currently being charged for comparable units in the private, unassisted market and must not be in excess of rents currently being charged by the owner for comparable unassisted units. Rent reasonableness can be assessed by comparing properties from: http://www.georgiahousingsearch.org/ ADDRESS Proposed Unit Unit #1 Unit #2 Unit #3 NUMBER OF BEDROOMS SQUARE FEET TYPE OF UNIT/CONSTRUCTION HOUSING CONDITION LOCATION/ ACCESSIBILITY AMENITIES: UNIT: SITE: NEIGHBORHOOD: AGE IN YEARS UTILITIES (TYPE) MONTHLY UNIT RENT HANDICAP ACCESSIBLE? A. Compliance with Payment Standard: _______________+ _______________ = __________________ 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 reasonable. is not reasonable. NAME: SIGNATURE: DATE: Emergency Solutions Grant 2013 Lead Screening Worksheet About this Tool The Lead Screening Worksheet is intended to guide grantees through the lead-based paint inspection process to ensure compliance with the rule. ESG staff can use this worksheet to document any exemptions that may apply, whether any potential hazards have been identified, and if safe work practices and clearance are required and used. A copy of the completed worksheet along with any additional documentation should be kept in each program participant's case file. Please see the ESG Lead-Based Paint Requirements Summary for additional information. INSTRUCTIONS To prevent lead-poisoning in young children, ESG grantees must comply with the Lead-Based Paint Poisoning Prevention Act of 1973 and its applicable regulations found at 24 CFR 35, Parts A, B, M, and R. Under certain circumstances, a visual assessment of the unit is not required. This screening worksheet will help program staff determine whether a unit is subject to a visual assessment, and if so, how to proceed. A copy of the completed worksheet along with any related documentation should be kept in each program participant's file. Note: ALL pre-1978 properties are subject to the disclosure requirements outlined in 24 CFR 35, Part A, regardless of whether they are exempt from the visual assessment requirements. Name of Participant Address City State Zip ESG Program Staff BASIC INFORMATION Unit Number PART 1: DETERMINE WHETHER THE UNIT IS SUBJECT TO A VISUAL ASSESSMENT If the answer to one or both of the following questions is `no,' a visual assessment is not triggered for this unit and no further action is required at this time. Place this screening worksheet and related documentation in the program participant's file. If the answer to both of these questions is `yes,' then a visual assessment is triggered for this unit and program staff should continue to Part 2. 1. Was the leased property constructed before 1978? Yes No 2. Will a child under the age of six be living in the unit occupied by the household receiving ESG assistance? Yes No 1 Emergency Solutions Grant 2013 PART 2: DOCUMENT ADDITIONAL EXEMPTIONS If the answer to any of the following questions is `yes,' the property is exempt from the visual assessment requirement and no further action is needed at this point. Place this screening sheet and supporting documentation for each exemption in the program participant's file. If the answer to all of these questions is `no,' then continue to Part 3 to determine whether deteriorated paint is present. 1. Is it a zero-bedroom or SRO-sized unit? Yes No 2. Has X-ray or laboratory testing of all painted surfaces by certified personnel been conducted in accordance with HUD regulations and the unit is officially certified to not contain lead-based paint? Yes No 3. Has this property had all lead-based paint identified and removed in accordance with HUD regulations? Yes No 4. Is the client receiving Federal assistance from another program, where the unit has already undergone (and passed) a visual assessment within the past 12 months (e.g., if the client has a Section 8 voucher and is receiving ESG assistance for a security deposit or arrears)? Yes (Obtain documentation for the case file.) No 5. Does the property meet any of the other exemptions described in 24 CFR Part 35.115(a). Yes No Please describe the exemption and provide appropriate documentation of the exemption. PART 3: DETERMINE THE PRESENCE OF DETERIORATED PAINT To determine whether there are any identified problems with paint surfaces, program staff should conduct a visual assessment prior to providing ESG financial assistance to the unit as outlined in the following training on HUD's website at: http://www.hud.gov/offices/lead/training/visualassessment/h00101.htm. If no problems with paint surfaces are identified during the visual assessment, then no further action is required at this time. Place this screening sheet and certification form (Attachment A) in the program participant's file. If any problems with paint surfaces are identified during the visual assessment, then continue to Part 4 to determine whether safe work practices and clearance are required. 1. Has a visual assessment of the unit been conducted? Yes No 2 Emergency Solutions Grant 2013 2. Were any problems with paint surfaces identified in the unit during the visual assessment? Yes Certification Form) No (Complete Attachment A Lead-Based Paint Visual Assessment PART 4: DOCUMENT THE LEVEL OF IDENTIFIED PROBLEMS All deteriorated paint identified during the visual assessment must be repaired prior to clearing the unit for assistance. However, if the area of paint to be stabilized exceeds the de minimus levels (defined below), the use of lead safe work practices and clearance is required. If deteriorating paint exists but the area of paint to be stabilized does not exceed these levels, then the paint must be repaired prior to clearing the unit for assistance, but safe work practices and clearance are not required. 1. Does the area of paint to be stabilized exceed any of the de minimus levels below? 20 square feet on exterior surfaces Yes No 2 square feet in any one interior room or space Yes No 10 percent of the total surface area on an interior or exterior component with a small surface area, like window sills, baseboards, and trim Yes No If any of the above are `yes,' then safe work practices and clearance are required prior to clearing the unit for assistance. PART 5: CONFIRM ALL IDENTIFIED DETERIORATED PAINT HAS BEEN STABILIZED Program staff should work with property owners/managers to ensure that all deteriorated paint identified during the visual assessment has been stabilized. If the area of paint to be stabilized does not exceed the de minimus level, safe work practices and a clearance exam are not required (though safe work practices are always recommended). In these cases, the ESG program staff should confirm that the identified deteriorated paint has been repaired by conducting a follow-up assessment. If the area of paint to be stabilized exceeds the de minimus level, program staff should ensure that the clearance inspection is conducted by an independent certified lead professional. A certified lead professional may go by various titles, including a certified paint inspector, risk assessor, or sampling/clearance technician. Note, the clearance inspection cannot be conducted by the same firm that is repairing the deteriorated paint. 1. Has a follow-up visual assessment of the unit been conducted? Yes No 2. Have all identified problems with the paint surfaces been repaired? Yes No 3. Were all identified problems with paint surfaces repaired using safe work practices? Yes No Not Applicable The area of paint to be stabilized did not exceed the de minimus levels. continued... 3 Emergency Solutions Grant 2013 4. Was a clearance exam conducted by an independent, certified lead professional? Yes No Not Applicable The area of paint to be stabilized did not exceed the de minimus levels. 5. Did the unit pass the clearance exam? Yes No Not Applicable The area of paint to be stabilized did not exceed the de minimus levels. Note: A copy of the clearance report should be placed in the program participant's file. LEAD-BASED PAINT VISUAL ASSESSMENT CERTIFICATION TEMPLATE I, _____(print name)________, certify the following: I have completed HUD's online visual assessment training and am a HUD-certified visual assessor. I conducted a visual assessment at ___(property address and unit number)___ on ___(date of assessment)____ . No problems with paint surfaces were identified in the unit or in the building's common areas. ____________________________________ (Signature) ____________________________________ (Date) Client Name: ________________________ Case Number: _______________________ 4 Emergency Solutions Grant ESG Lead-Based Paint Document Checklist 2013 About this Tool The following checklist provides ESG grantees with an overview of common documents that can be used to verify compliance with the Lead-Based Paint Poisoning Prevention Act. Note that this checklist does not cover all of the documentation that providers would want to include in all instances. For example, additional documentation may be required if the property is found to meet exemptions listed under Part 2 of the Lead Screening Worksheet. DOCUMENT NAME Application Screenshot of property record from online tax database Lead Screening Worksheet Lead-Based Paint Visual Assessment Certification Owner Certification (if applicable) Clearance Report (if applicable) Documentation of ongoing maintenance activities: Visual Assessment Certification Forms Clearance report from each maintenance job involving painted surfaces above the de minimis threshold Notice of lead hazard reduction for each maintenance job involving painted surfaces Documentation of response to EIBLL child: Copies of risk assessment Abatement or clearance report Relocation documents Correspondence with health department PURPOSE 9 Documents age of children Documents age of property Documents exemptions (additional documentation will vary based on exemption) Documents that a visual assessment was conducted and problems with paint surfaces were not identified Documents owner certification that any identified problems with paint surfaces have been repaired and that safe work practices were followed, as applicable Documents that unit passed clearance Documents that a visual assessment is performed at least annually during the assistance period and that any deteriorated paint was appropriately addressed (including clearance and notice of lead hazard reduction) Documents that if an EIBLL child was identified in the unit, the situation was addressed in accordance with the Lead Safe Housing Rule. Emergency Solutions Grant 2013 ESG Lead-Based Paint Property Owner Certification Form About this Tool The ESG Lead-Based Paint Property Owner Certification Form is a tool program staff can use to have property owners/managers certify that all paint stabilization activities have been completed in accordance with guidelines when formal clearance is not required (or as additional documentation when formal clearance is required). A copy of the completed form along with any additional documentation (i.e., a copy of the clearance report) should be kept in each program participant's file. INSTRUCTIONS To prevent lead-poisoning in young children, the ESG program must comply with the Lead-Based Paint Poisoning Prevention Act of 1973 and its applicable regulations found at 24 CFR 35, Parts A, B, M, and R. If a visual assessment reveals problems with paint surfaces, property owners/managers must repair all identified problems with paint surfaces in accordance with the guidelines of 24 CFR 35, Parts A, B, M, and R, prior to a unit receiving ESG assistance. Property owners/managers should complete this form to certify that all identified problems with paint surfaces have been repaired/stabilized in accordance with the guidelines. 1. Have all identified problems with the paint surfaces been repaired? Yes No 2. Have all identified problems with paint surfaces been repaired using safe work practices? Yes No Not Applicable The area of paint to be stabilized did not exceed the de minimus levels. 3. Was a clearance exam conducted by an independent, certified lead professional? Yes No Not Applicable The area of paint to be stabilized did not exceed the de minimus levels. 4. Did the unit pass the clearance exam? Yes No Not Applicable The area of paint to be stabilized did not exceed the de minimus levels. Name of Tenant Address Unit Number City State Zip Name of Property Owner/Manager Property Owner/Manager Signature Date Name ESG Program Staff ESG Program Staff Signature Date Emergency Solutions Grant 2013 Understanding the Lead-Based Paint Requirements: Guidance for ESG Grantees About this Resource Childhood lead poisoning is a major environmental health problem in the United States, especially for low-income families in poor living conditions. If not detected early, children with high levels of lead in their bodies can suffer from damage to the brain and nervous system, behavioral and learning problems (such as hyperactivity), slowed growth, hearing problems, and headaches. To prevent lead-poisoning in young children, ESG grantees must comply with the Lead-Based Paint Poisoning Prevention Act of 1973 and its applicable regulations found at 24 CFR 35, Parts A, B, M, and R. This document summarizes the lead-based paint requirements and provides guidance for carrying out each step. SECTION I: OVERVIEW OF REQUIREMENTS & APPLICABILITY UNDER ESG The lead-based paint requirements exist to protect vulnerable families from potential health hazards. To prevent lead-poisoning in young children, ESG grantees must comply with the Lead-Based Paint Poisoning Prevention Act of 1973 and its applicable regulations found at 24 CFR 35, Parts A, B, H, J, K, M, and R. As agencies that provide assistance to and advocate on behalf of disadvantaged populations, it is important to understand that the lead rule is a tool that helps you ensure the safety and well-being of your clients. This guidance was developed to assist grantees and subgrantees in understanding how the lead-based paint regulations apply to ESG. Please refer to the regulations for additional information. Under ESG, the rule is that a lead-based paint visual assessment must be completed for all units that meet the three following conditions: o The household living in the unit is being assisted with ESG financial assistance (rent o assistance, utilities assistance, utility/security deposits, or arrears). o The unit was constructed prior to 1978. o A child under the age of six is or will be living in the unit. Under ESG, the lead requirements apply regardless of whether a household is remaining in an existing unit or moving to a new unit. The visual assessment must be completed prior to ESG assistance being provided, and annually thereafter. Grantees and subgrantees (ESG program staff) are responsible for ensuring that property owners and managers meet the lead-based paint requirements. It may be helpful for grantees to think about the requirements in two categories: 1. Disclosure requirements. Disclosure requirements are triggered for ALL properties constructed prior to 1978. These requirements require that lessors (property owners or managers) provide tenants with: HUD's disclosure form for rental properties disclosing the presence of known and unknown lead-based paint; AND A copy of the "Protect Your Family from Lead in the Home" pamphlet. Both the disclosure form and pamphlet are available at: http://www.hud.gov/offices/lead/enforcement/disclosure.cfm 1 Emergency Solutions Grant 2013 As explained, this requirement actually relates to property owners/managers, but sharing this information with your clients (or ensuring they have received it) is an easy thing to do and will make your job easier. ESG assessments are an important opportunity to educate clients about the potential hazards related to lead and their rights as tenants. Informed tenants are more likely to watch for potential problems in their home and proactively work with landlords to address any issues. 2. The Visual Assessment and Beyond. 1 As explained in the ESG Notice, visual assessments for ESG funded units are only triggered under certain circumstances: 2 The leased property was constructed before 1978; AND A child under the age of six will be living in the unit occupied by the household receiving ESG assistance. Depending on the results of the visual assessment, additional steps may be required before assistance can be provided for that unit. In Section 2, this guidance will take a step-by-step look at what happens during and after the visual assessment. Exceptions to the Rule There are certain exceptions to the rule. Visual assessments by ESG staff are not triggered under the following circumstances: It is a zero-bedroom or SRO-sized unit; X-ray or laboratory testing of all painted surfaces by certified personnel has been conducted in accordance with HUD regulations and the unit is officially certified to not contain lead-based paint; The property has had all lead-based paint identified and removed in accordance with HUD regulations; The client is receiving Federal assistance from another program, where the unit has already undergone a visual assessment within the past 12 months e.g., if the client has a Section 8 voucher and is receiving ESG assistance for a security deposit or arrears (note, in such cases, ESG staff are required to obtain documentation that a visual assessment has been conducted from the agency administering the other form of assistance for the ESG case file); or It meets any of the other exemptions described in 24 CFR Part 35.115(a). If any of the conditions outlined above are met, ESG program staff simply need to document the condition by completing the ESG Lead Screening Worksheet (available on the HUD HRE) and placing a copy in the case file. (Note: While grantees are required to document compliance with the lead rule, they are not required to use this particular screening worksheet or any of the other templates mentioned in this paper. These tools were developed as samples to assist grantees who may be looking for resources to use in their local programs.) Remember, regardless of these exceptions, all properties are still subject to the disclosure requirements. 1 Note that visual assessments are sometimes called inspections though the terms should not be used interchangeably because they imply different levels of rigor, as explained later in this guidance. 2 Note these requirements may be different for other HUD programs. 2 Emergency Solutions Grant 2013 SECTION II: A STEP-BY-STEP GUIDE TO COMPLIANCE As explained above, the lead-based paint regulations require certain responses to potential lead-based hazards. Some activities must be conducted by ESG program staff while others are generally conducted by property owners/managers. Regardless of who is the responsible party, ESG program staff should work closely with assisted households and property owners/manager to ensure that the activities described below have been conducted prior to approval of ESG assistance for that unit. Program staff should consider sharing the following documents available on Homelessness Resource Exchange at www.hudhre.info with property owners/managers as well as residents to outline responsibilities and provide additional guidance: Instructions for Property Owners Template Instructions for Residents Template ESG Program Staff Responsibilities The following information outlines the steps that should be taken by ESG program staff: 1. Determine whether lead-based paint requirements are triggered. Prior to providing a household with ESG assistance, program staff must first determine whether lead-based paint requirements are triggered. To do this, they must determine whether the unit was built prior to 1978 and a child under the age of six is or will be residing in the unit. Program staff should complete the ESG Lead Screening Worksheet for the case file and document any exemptions. If any exemptions are met, then lead-based paint requirements are not triggered and no further action is needed. A copy of the ESG Lead Screening Worksheet can be found on the Homelessness Resource Exchange at www.hudhre.info. Determining the Age of the Unit Program staff should use formal public records, such as tax assessment records, to establish the age of a unit. These records are typically maintained by the state or county and will include the year built or age of the property. In most areas, these records are available online. If you are uncertain where to find this information, a quick internet search should help you locate the data you need. In the search field, try combining your county name with one of the following phrases: - "property tax records" - "property tax database" - "real property sales" For example, if you enter "DC property tax records," the first search result is a public database that can be used to determine the age of a property located within the District of Columbia. Once you have found it, remember to bookmark the page for future reference! Remember to print out a copy of the screenshot for the case file. If you have trouble finding this information online, contact your local Office of Tax and Revenue for assistance. If not available online, the information is public and can be requested from the local authorities. (Note, the taxing authority and the assessment entity may be separate governmental entities and office names vary by locality.) 2. Inform ESG client and property owner of the lead-based paint requirements and schedule visual assessment. Families living in poverty face many challenges, such as poor living conditions and 3 Emergency Solutions Grant 2013 exposure to toxins such as lead-based paint. Since annual visual assessments are an ESG requirement, program staff should use the opportunity to educate families with young children about the dangers of lead-based paint. Program staff should ensure that clients know what to look for within their home (or as they are searching for a new unit). Similarly, program staff should ensure that property owners/managers understand their responsibilities with regard to lead-based paint hazards so that they are also doing routine assessments to identify and repair deteriorated paint. Because HUD prohibits grantees and subgrantees from making payments directly to clients, program staff will have to be in touch with property owners/landlords to discuss payment and conditions related to payment, including lead-based paint requirements. Because assistance cannot be provided until the visual assessment has been completed and the unit cleared, it is important for ESG staff to schedule the visual assessment as quickly as possible. The case manager should complete the screening worksheet (discussed above) upon determining household eligibility for ESG assistance and schedule the assessment immediately. If subsequent conversations with the property owner reveal that the property meets an exception, than the assessment can be cancelled. However, it's better to get the assessment scheduled right away since lengthy delays could result in the loss of the unit (e.g., if the tenant is in arrears). 3. Conduct visual assessment. A visual assessment must be conducted prior to providing ESG financial assistance to the unit, and on an annual basis thereafter (as long as assistance is provided). Visual assessments must be conducted by a HUD-Certified Visual Assessor. It is important to note that a HUD-Certified Visual Assessor is not equivalent to a Certified Clearance Examiner. Anyone may become a HUD-Certified Visual Assessor by successfully completing a 20-minute online training on HUD's website at: http://www.hud.gov/offices/lead/training/visualassessment/h00101.htm. The training teaches individuals how to identify deteriorated paint and how deteriorated paint must be treated. Grantees/subgrantees may choose to have their program staff complete the visual assessments, or they may procure services from a contractor. When determining how your agency will conduct the assessments, a primary consideration should be the availability of the staff/contractor to schedule and complete the assessments quickly. If program staff are being used to complete the visual assessments, your agency may find it helpful (i.e., less disruptive and more efficient) to identify specific days or blocks of time for completing visual assessments. Note that if ESG financial assistance is being used to help a client move into a new unit, an inspection must also be conducted to ensure the unit meets the minimum habitability standards outlined on the ESG Notice. 3 In cases where both a lead-based paint visual assessment and a habitability inspection are required, the most efficient and cost effective solution would be to have the same individual complete both at the same time. Note that the cost of conducting visual assessments and habitability inspections are an eligible ESG expense under the Financial Assistance category. 4. Identify risks and compare to "de minimis" level. During a visual assessment, the assessor must determine the level of any identified problems with paint surfaces and compare it to the "de minimis" level.4 Under the Lead act, the de minimus level is as follows: 20 square feet on exterior surfaces; 2 square feet in any one interior room or space; or 4 Emergency Solutions Grant 2013 10 percent of the total surface area on an interior or exterior component with a small surface area, like window sills, baseboards, and trim. All deteriorated paint identified during the visual assessment must be repaired. However, if the area of paint to be stabilized exceeds the de minimis level, the use of lead safe work practices and clearance is required. If deteriorating paint exists but the area of paint to be stabilized does not exceed this level, then safe work practices and clearance are not required. If deteriorating paint is not identified, the unit can be cleared for assistance. Staff should document the level of identified problems with paint surfaces using the Lead Safe Housing Requirements Screening Worksheet. 5. Make assistance determination. If a visual assessment reveals problems with paint surfaces, program staff cannot approve the unit for assistance until the deteriorating paint has been repaired. At this point, program staff must make a decision: work with the property owner/manager to complete needed paint stabilization activities and clearance, work with the household to locate a different (lead-safe) unit, or refer the client to a different program if ESG assistance cannot be provided. Which option the grantee chooses will depend on a number of variables. The following are some questions to consider when making this decision: Is ESG assistance being used to help the participant obtain a new unit or retain an existing unit? If the grantee is helping a household obtain new housing, there may be more flexibility with regard to the timeframe (i.e., there may be a few weeks between identification of the unit and the move-in date). Staff should conduct the visual assessment prior to the participant signing the lease so they can help negotiate any needed repairs. If ESG assistance is being used for prevention assistance, how much time is there to save the housing situation, and what is the relationship with the landlord? For participants that are housed but at imminent risk of homelessness (e.g., because they are several months behind on their rent), there may not be much time. If the landlord has already initiated eviction proceedings, he or she may or may not be willing to work with the household. Thus, it's important to contact the landlord directly and assess the situation. How appropriate is the current unit for the household? If the existing unit is not particularly suitable for the household either because of cost, size, location, or some other reason it may make more sense to focus on relocating the household. What is the condition of the local housing market? How expensive/difficult would it be to relocate the participant to a new unit? In contrast, how difficult would it be for the landlord to fill the unit if it was vacated? (Depending on the situation, you may have more or less leverage.) Are resources available to assist with the paint stabilization? ESG cannot be used for stabilization, so if the landlord is unwilling or unable to make the needed repairs, is there any other agency/program that can assist? 3 The minimum standards for housing unit inspections are the housing habitability standards described in Appendix C of the ESG Notice. These standards apply only when a program participant is receiving financial assistance and moving into a new unit. They do not apply to persons served with ESG prevention assistance in a unit in which the program participants were already residing. The habitability standards are different from the Housing Quality Standards (HQS) used for other HUD programs. In contrast to HQS inspections, the habitability standards do not require a certified inspector. For example, ESG project staff or staff from or hired by an agency of the grantee's local government can conduct the 5 Emergency Solutions Grant 2013 habitability inspection. 4 De minimus is a Latin expression that, in the risk assessment world, refers to a level of risk that is too minimal to cause concern. 6. Confirm all identified deteriorated paint has been stabilized. Program staff should work with property owners/managers to ensure that all deteriorated paint identified during the visual assessment has been stabilized. If the area of paint to be stabilized does not exceed the de minimus level, a clearance exam is not required. In these cases, the ESG program staff should confirm that the identified deteriorated paint has been repaired and document the case file. If the area of paint to be stabilized exceeds the de minimus level, program staff should ensure that the clearance inspection is conducted by an independent certified lead professional. (A certified lead professional may go by various titles, including a certified paint inspector, risk assessor, or sampling/clearance technician.) Note, the clearance inspection cannot be conducted by the same firm that is repairing the deteriorated paint. Local community development, housing, or health departments are often able to provide this testing. As noted above, ESG funds cannot be used for the repair/stabilization of lead-based paint hazards. However, one clearance inspection is considered an eligible ESG expense (under the Financial Assistance category). If the unit does not pass the initial clearance inspection, ESG funds may not be used to pay for additional inspections. Locating a Certified Lead Professional To locate a certified lead professional in your area: Call your state government (health department, lead poison prevention program, or housing authority). Call the National Lead Information Center at 1-800-424-LEAD (5323). Go to the US Environmental Protection Agency website at http://cfpub.epa.gov/flpp/ and click on "certified abatement/inspection firms." Program staff should also consider having the property owner/manager certify that all paint stabilization activities have been completed and ongoing maintenance will be conducted by filling out the ESG Program-Owner Certification Template, available on the Homelessness Resource Exchange at www.hudhre.info. Response to a child with elevated blood leads levels. In cases where it is brought to the attention of program staff that a child under the age of six living in a ESG-assisted unit is found to have elevated blood lead levels, the response process established at 24 CFR 35.1225 takes effect, which includes a risk assessment and interim controls and information exchange with the health department. Conduct ongoing lead-based paint monitoring. Program staff must conduct a visual assessment of the stability of painted surfaces on an annual basis during the assistance period. 6 Emergency Solutions Grant 2013 Property Owner/Manager Responsibilities The following information outlines the responsibilities of a property owner/manager: 1. Distribution of pamphlets and disclosure notice to occupants. For ALL units built prior to 1978, property owners/managers are required to provide lessees (tenants signing the lease) with: A copy of the "Protect Your Family from Lead in the Home" pamphlet; AND HUD's disclosure form for rental properties. Program staff dealing with rental properties built prior to 1978 should ensure property owners/managers provide these documents to tenants. Program staff, in addition to owners/managers, may also choose to provide disclosure notices to the lessee (tenant signing the lease) on the potential existence of lead-based paint. Both the disclosure form and pamphlet are available at: http://www.hud.gov/offices/lead/enforcement/disclosure.cfm 2. Perform paint stabilization. If a visual assessment reveals problems with paint surfaces, the property owner will be notified of the need for paint stabilization and assistance cannot be approved until corrective actions have been taken and the unit has achieved clearance (as appropriate per the identified de minimus level). It is the responsibility of any property owner participating in the program to: Protect the residents and their belongings Repair the paint Conduct cleanup Address other lead-based paint-related concerns Obtain clearance (if deteriorated surface is more than the de minimis) Failure by the property owner to fulfill their responsibilities on their own or with the assistance of the program prohibits the program from assisting a tenant in that unit. 3. Use safe work practices. If the area is larger than the de minimis level, safe work practices must be used. Examples of safe work practices include: Wet sanding or wet scraping; Protection of the worksite to keep lead dust from leaving the worksite or getting onto the resident's belongings; and Cleaning of the worksite with HEPA vacuuming and detergents. If the area is smaller than the de minimis level, safe work practices do not have to be used. It is recommended, however, that all practices include: Surface preparation to minimize the amount of dust released (wet sanding or scraping is still recommended to minimize the release of dust); and Cleanup using conventional cleaning methods. 4. Obtain clearance. Property owners/managers must ensure that all deteriorated paint identified during the visual assessment has been stabilized. If the area of paint to be stabilized does not exceed the de minimus level, a clearance exam is not required. In these cases, the ESG program staff should confirm that the identified deteriorated paint has been repaired and document this in the case file. 7 Emergency Solutions Grant 2013 If the area of paint to be stabilized exceeds the de minimus level, clearance by an independent, certified lead professional, such as a certified paint inspector, risk assessor, or sampling/clearance technician, is required. The clearance inspection cannot be conducted by the same firm that is repairing the deteriorated paint. Local community development, housing, or health departments are often able to provide this testing. It is the property owners/managers' responsibility to obtain clearance. However, they may work closely with ESG program staff throughout this process. Specifically, ESG program staff can pay for the first clearance inspection using ESG funds. If the unit does not pass the initial clearance inspection, ESG funds may not be used to pay for additional inspections. 5. Provide Notice of Lead Hazard Reduction to tenants. Within 15 days of completion of the Lead Hazard Reduction activities, including paint stabilization, the property owner/manager must provide a Notice of Lead Hazard Reduction to tenants or post the notice in a common area where the tenants will see it. If applicable, the notice must contain the clearance results. 6. Conduct ongoing lead-based paint maintenance. The property owner/manager should assess the stability of painted surfaces periodically to ensure there are no lead-based paint hazards in the assisted unit, repairing any deteriorating paint as soon as it is identified. SECTION III: RESOURCES Lead professionals, training providers, and HUD-sponsored Lead Safe Work Practices training listings can be accessed at www.leadlisting.org or 1-888-LEADLIST. For more information on the Federal training and certification program for lead professionals, contact the National Lead Information Center (NLIC) at: http://www.epa.gov/lead/pubs/nlic.htm or 1-800-424-LEAD to speak with an information specialist. The Lead Safe Housing Rule as well as a HUD training module to help recipients of CPD administered funds effectively implement the requirements of the Lead Safe Housing Rule in their programs can be accessed at: http://www.hud.gov/offices/cpd/affordablehousing/training/web/leadsafe/ 8 Emergency Solutions Grant 2013 Instructions for Property Owners with Tenants Receiving ESG Assistance About this Tool This tool summarizes and outlines responsibilities of property owners/managers under Lead-Based Paint Poisoning Prevention Act of 1973 (24 CFR 35). Program staff should consider sharing this tool with property owners/managers to inform them of their responsibilities. Lead-based paint remains a serious threat to children's health and well-being. Consider the following facts: An estimated 890,000 U.S. children have too much lead in their bodies. Nationwide, an estimated 38 million homes have lead-based paint. The most common sources of lead hazards are generated in a residential environment. To better protect young children from the dangers of lead-based paint in their homes, the Department of Housing and Urban Development (HUD) has issued The Lead Safe Housing Rule (24 CFR 35). Under the new Homelessness Prevention and Rapid Re-Housing Program (funded under the American Recovery and Reinvestment Act of 2009), grantees administering ESG financial assistance must comply with the Lead Safe Housing Rule. ESG financial assistance includes short- and medium-term rental assistance, as well as one- time rent payments, rental and utility arrears payments, security deposits, utility deposits, and utility assistance. The rule applies to all units built before January 1978 in which children under the age of six years will be living in the next 12 months. The Lead Safe Housing Rule affects ESG grantees and landlords in the following ways: The ESG grantee must conduct a visual assessment before assistance can be approved and annually thereafter during the period of assistance. All painted surfaces, interior and exterior, must be inspected for deteriorated paint (not just those surfaces within reach of a child). If deteriorated paint is identified, the paint must be stabilized. If the area of paint to be stabilized exceeds the "de minimus" level, 1 paint stabilization must be done by qualified workers using safe work practices. See Attachment 1. Note that ESG funds cannot be used for stabilization activities. Once work on the defective paint surface is completed and the surrounding area cleaned, a certified lead professional must conduct a clearance examination (if the area of deteriorated paint exceeded the de minimus level).2 If the area of deteriorated paint did not exceed the de minimus level, the grantee 1 Safe work practices and clearance are not required when maintenance or hazard reduction activities do not disturb painted surfaces below the de minimis thresholds defined below: 20 square feet (2 square meters) on exterior surfaces; 2 square feet (0.2 square meters) in any one interior room or space; or 10 percent of the total surface area on an interior or exterior type of component with a small surface area (such as window sills, baseboards, and trim). 2 A certified lead professional may go by various titles, including a certified paint inspector, risk assessor, or sampling/clearance technician. 1 Emergency Solutions Grant 2013 will conduct a follow-up visual assessment. Note: The grantee and landlord should coordinate to identify a certified lead professional and schedule the examination.3 The [ESG grantee (or) landlord] will pay for the first clearance examination.4 If a unit fails the clearance examination, the landlord is responsible for re-cleaning the unit and hiring a certified clearance examiner to perform a second clearance. No ESG assistance can be provided until the unit passes the follow-up visual assessment or clearance exam, as appropriate. After work is complete, the landlord must provide a Notice of Lead Hazard Reduction to the resident. See Attachment 2. The ESG grantee will conduct an annual re-inspection for deteriorated paint throughout the course of the ESG assistance. As long as ESG assistance continues, the landlord is required to stabilize any deteriorated paint in a lead-safe manner. See Attachment 3. The following resources are provided to help you implement these requirements: Attachment 1: Instructions on how to stabilize paint Attachment 2: Sample Notice of Lead Hazard Reduction Attachment 3: Instructions for Ongoing Maintenance The ESG grantee will work with landlords to facilitate compliance. For more information, please contact ________________________ at __________________________. Staff name Telephone Number 3 To locate a certified lead professional in your area: (1) Call your state government (health department, lead poison prevention program, or housing authority). (2) Call the National Lead Information Center at 1-800-424-LEAD (5323). (3) Go to the US Environmental Protection Agency website at http://cfpub.epa.gov/flpp/ and click on "certified abatement/inspection firms." 4 Note to grantees: ESG funds cannot be used for lead-based paint stabilization and clean-up work, however funds can be used to pay for one clearance examination. It is up to the grantee to decide if they wish to use funds for the exam. Based on their local decision, grantees should circle the appropriate response prior to providing this guidance to landlords. 2 Emergency Solutions Grant 2013 ATTACHMENT 1: PAINT STABILIZATION INSTRUCTIONS Repairing, removing, or maintaining lead-based paint improperly can spread lead-contaminated dust throughout the home. It is very important to use safe work methods when working on surfaces that may contain lead-based paint. 1. Use qualified workers. In homes receiving HUD assistance and where deteriorated paint exceeds the de minimus thresholds defined in Attachment 3, paint stabilization must be done by workers who are specially trained in lead safe work practices. Alternatively, the workers may be supervised by a state-certified abatement supervisor. The ESG grantee can help you identify properly trained contractors. Note, the use of qualified workers is not required when maintenance or hazard reduction activities do not disturb painted surfaces below the de minimis thresholds, though use of lead-safe work practices is always recommended. 2. Use the proper equipment. You will need the proper tools and supplies to do the job correctly. In addition to tools such as scrapers and putty knives, it is important to have: A HEPA vacuum (a vacuum equipped with a very fine filter capable of filtering very small particles of lead); double-sided mop bucket and mop; a good household detergent; ample disposable paper towels or rags; plastic sheeting; tack cloth; disposal waste bags; wet sanding blocks; and misting bottle filled with water. 3. Set up the work area properly. The key is to contain the dust and debris created by the work. Create a barrier between the work area and the rest of the house. Use plastic sheeting over the doorways to seal off the area and protect the rest of the house from exposure. Work over a plastic drop cloth (never use cloth) to catch any debris created as a result of paint removal. Wear disposable shoe covers and remove them before exiting the work area, or step onto a tack cloth to remove paint chips and dust from the soles of shoes. Keep doors and windows closed to prevent dust from blowing and close off vents to central air or heating systems to avoid spreading dust to other parts of the house. Remove all furniture, or cover tightly with plastic sheeting. Do not allow children or pregnant women into the work area. 4. Use safe work practices. If the deteriorated paint surfaces exceed the de minimus thresholds defined in Attachment 3, then safe work practices must be used. Never remove lead-based paint by dry-sanding, dry scraping or burning. Use power sanders, grinders, and planers only with a HEPA exhaust attachment. Using your misting bottle, wet the painted surface before sanding with a wet sanding block or scraping. Be sure to work over a plastic drop cloth to catch any large particles. Do not eat, smoke, or chew gum while working. Note, safe work practices are not required when maintenance or hazard reduction activities do not disturb painted surfaces below the de minimis thresholds. 5. Clean as you work. Be sure to wet clean the areas you are working on as you go along. Though it will be necessary to clean the entire house at the end of the project, it is important to clean as you work in order to keep lead-contaminated dust from spreading. Clean using a good household detergent. Rinse your cleaning utensils in clean water. 6. Dispose of waste properly. When the work is done, mist the plastic sheeting with water to keep down the dust. Roll the plastic sheet up, keeping the dirty side in. Pick up any paint chips or other debris that may have fallen elsewhere. Be sure to place all disposable items used in the repair and clean up into plastic waste bags. The bags must be tightly sealed and can generally be disposed of with the household trash.* Once the bags are sealed, do not reopen them. 7. Obtain clearance. If the deteriorated paint surfaces exceed the de minimus thresholds defined in Attachment 3, then clearance must be obtained after the paint has been stabilized and the work area cleaned. The results of this test will tell you if your work practices and final cleaning have been effective at removing lead- contaminated dust. Clearance is not required when maintenance or hazard reduction activities do not disturb painted surfaces below the de minimis thresholds. *Check with your State lead program to ensure there is no state regulation prohibiting disposal with household trash. 3 Emergency Solutions Grant ATTACHMENT 2: SAMPLE NOTICE OF LEAD HAZARD REDUCTION Property Address:__________________________ Today's Date:________________________ Summary of the Hazard Reduction Activity: 2013 Start Date:______________________ Completion Date:______________________ Location and type of activity. (List the location and type of activity conducted, or attach a copy of the summary page from the clearance report providing this information.) ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Date(s) of clearance testing:___________________________________________________ Summary of results of clearance testing: (a) _____________ Clearance testing was not performed as paint stabilization did not exceed de minimus levels. (b) _____________ Clearance testing showed clearance was achieved. (c) _____________ Clearance testing showed clearance was not achieved. List any components (e.g., kitchen-door, bedroom-windows) with known lead-based paint that remain in areas where activities were conducted. _______________________________________________________________________________________ _______________________________________________________________________________________ Person who prepared this summary notice Printed Name:____________________________ Signature:________________________________ Title:____________________________________ Organization:_____________________________ Address:________________________________________________________________________________ Phone:________________________________ Fax:___________________________________________ Owner:_________________________________ Date:__________________________________________ (Give to Property Owner with work write-up) If you have any questions about this summary, please contact __________________ at ___________________. 4 Emergency Solutions Grant 2013 ATTACHMENT 3: ONGOING MONITORING AND MAINTENANCE REQUIREMENTS Property owners/landlords should take the following steps to ensure that paint is not deteriorating and creating lead-contaminated dust and paint chips, as it will help prevent children from being lead poisoned. 1. Regularly Check Repairs for Deterioration, Paint Chips, and Dust Property owners must monitor painted surfaces at least annually and at unit turnover. Check to see if: New evidence of deterioration or paint failure is present. The cause of the problem was corrected. 2. Maintain Surfaces and Work Safely Stabilize deteriorated paint; Use safe work practices and qualified workers for all maintenance activities;** 3. Conduct Clean-Up and Clearance Activities Clean thoroughly after all maintenance work; Seek clearance of the work area using a certified lead professional (risk assessor, clearance examiner, or lead sampling technician);** If the work area does not pass clearance, re-clean and perform clearance again. ** Note Safe work practices and clearance are not required when maintenance or hazard reduction activities do not disturb painted surfaces below the de minimis thresholds defined below: 20 square feet (2 square meters) on exterior surfaces; 2 square feet (0.2 square meters) in any one interior room or space; or 10 percent of the total surface area on an interior or exterior type of component with a small surface area (such as window sills, baseboards, and trim). 5 Emergency Solutions Grant 2013 Instructions for Residents Receiving ESG Assistance About this Tool This tool provides residents with an overview of the Lead-Based Paint Poisoning Prevention Act, the responsibilities of property owners/managers, and their rights as tenants. Program staff should consider sharing this resource with program participants living in units constructed prior to 1978. The purpose of this notice is to inform you that because your home was built prior to January 1978, it may contain lead-based paint. Lead from paint, paint chips, and dust can pose health hazards if not managed properly. Lead exposure is especially harmful to young children and pregnant women. Your landlord should have already provided you with a pamphlet on lead poisoning prevention, as well as a disclosure form on the lead-based paint or lead-based paint hazards in your home. The attached handout - entitled What Are the Sources of Lead in Your Home? - provides important information. For additional information on lead-based paint and lead hazards, please call the National Lead Information Center at 1-800-424-LEAD or visit the web at: http://www.hud.gov/offices/lead/index.cfm; or http://www.epa.gov/lead/ Regulations under The Lead Safe Housing Rule helps to ensure that your home is safe for occupancy. In order for you to help keep your home safe, please notify the management if you see any paint that is chipping, peeling, flaking, or otherwise damaged. The bottom of this page can be detached and submitted to the management to bring attention to any lead-based paint concerns. Lead-Based Paint Concern To ______________________________ (Landlord/Property Management Company) I am submitting this notice because I have observed the following: Paint in bad condition (chipping, peeling, flaking, etc.) Other ________________________________ Location of Paint Concern: Exterior (location): ________________________________________________________ Interior (location): ________________________________________________________ Name: ____________________________ Address: ____________________________ Date: ____________________________ 1 Emergency Solutions Grant 2013 WHAT ARE THE SOURCES OF LEAD IN YOUR HOME? There are four major sources of lead that can pose a health hazard to people in and around the home. The sources are: 1. Lead-based paint. Lead-based paint can be found in housing built prior to 1978. It can be a hazard, especially if it deteriorates or if it is disturbed during maintenance or through normal wear and tear. If lead-based paint is peeling, chipping, chalking, or cracking, it will create lead-contaminated dust that poisons children through normal hand-to-mouth activity. Children may also eat paint chips or chew on painted surfaces that are accessible to them, resulting in poisoning. Even lead- based paint that appears to be in good condition can be a problem if it is on surfaces that get a lot of wear and tear, such as door jambs and window tracks. It is important to remove the causes of deteriorating paint such as water leaks. Lead paint that is deteriorating can be repaired by repainting with a good latex paint or lead sealer. 2. Lead-contaminated dust. Lead-contaminated dust is created when lead-based paint is sanded or scraped during maintenance or repair, or just through every day wear and tear. When maintenance or renovations take place, the dust from these operations settles on surfaces such as floors, countertops, window-sills, and furniture. If the paint being worked on contains lead, the lead is deposited on surfaces as dust. Window tracks and door jambs can be another source of lead- contaminated dust. If these components rub during normal opening and closing, lead- contaminated dust can be created and deposited on surfaces throughout the home. Lead from work done on house exteriors can be tracked into the home, becoming an additional source of lead dust. After routine home maintenance or remodeling/renovation and painting, the home should be thoroughly cleaned to remove any dust that may be left behind because it may contain lead. Lead dust sampling should then be performed to verify that the cleaning was effective. 3. Lead-contaminated soil. Soil can become contaminated when exterior lead-based paint deteriorates and gets in the soil. Homes near certain industries such as smelters or battery manufacturers may have lead into the soil as a result of these operations. Past use of leaded gasoline has also left lead deposits in our nation's soil. Playgrounds and gardens should not be placed in areas where the soil is contaminated with lead. Soil can be tracked into the home so it is important for workers to clean shoes or remove them before entering the home. 4. Lead-contaminated drinking water. Drinking water can be contaminated with lead, regardless of the water's source. Many faucets in homes and on store shelves contain leaded components that can leach lead into the water. Leaded solder in household piping and leaded components in well pumps have been in use for many years, and continue to leach lead into the drinking water of thousands of homes even today. Many public water delivery systems still have old lead piping through which the water must pass before it reaches the home. Water with a high pH has a tendency to leach more lead than water with a neutral pH, and warm water leaches more lead than cold. Allow cold water to run before drinking. The following are sources of information about lead-based paint in your home: National Lead Information Center (NLIC) is a clearinghouse for information on lead that provides copies of pamphlets, reports, and other resources. (1-800-424-LEAD) Safe Drinking Water Hotline provides information and assistance to the public on safe drinking water. (1-800-426-4791) 2 HMIS DATA QUALITY REPORT FOR ESG DCA COMPLIANCE TESTING (1234) 7/1/2011 - 6/30/2012 Missing and "Don't Know"/"Refused" Responses Data Element Total Clients Applicable Records M 91 % DKR M+DKR Total Adults 88 Total Unaccompanied Children 0 Total Leavers 87 First Name 91 0 0 0.00% Last Name 91 0 0 0.00% Social Security Number 91 0 35 38.46% Date of Birth 91 1 2 3.30% Race 91 0 0 0.00% Ethnicity 91 0 0 0.00% Gender 91 0 0 0.00% Veteran Status 88 0 1 1.14% Disabling Condition 91 0 2 2.20% Residence Prior to Prog. Entry 88 0 1 1.14% Zip Code of Last Permanent Address 88 0 19 21.59% Housing Status (at entry) 91 0 0 0.00% Income (at entry) 91 66 18 92.31% Income (at exit) 87 0 87 100.00% Non-Cash Benefits (at entry) 91 69 18 95.60% Non-Cash Benefits (at exit) 87 0 86 98.85% Physical Disability (at entry) 91 91 0 100.00% Physical Disability (at exit) 87 87 0 100.00% Developmental Disability (at entry) 91 91 0 100.00% Developmental Disability (at exit) 87 87 0 100.00% Chronic Health Condition (at entry) 91 91 0 100.00% Chronic Health Condition (at exit) 87 87 0 100.00% HIV/AIDS (at entry) 91 91 0 100.00% HIV/AIDS (at exit) 87 87 0 100.00% Mental Health (at entry) 91 91 0 100.00% Mental Health (at exit) 87 87 0 100.00% Substance Abuse (at entry) 91 91 0 100.00% Substance Abuse (at exit) 87 87 0 100.00% Domestic Violence (at entry) 88 88 0 100.00% Domestic Violence (at exit) 88 0 0 0.00% Destination 87 0 53 60.92% Total 2770 1292 322 58.27% Miscellaneous Data Element Total Beds # or % 18 Average Bed Utilization* 58.54% Excessive 100.00% Length of Stay** Invalid 2 Length of Stay Impartial or non-SSN ID 1.10% M DKR OK Goal * A very high or low bed utilization could be an indication that bed inventory is not accurate. High utilization could also be caused by a failure to discharge clients from HMIS, and low utilization could be caused by a failure to enroll clients in HMIS. The ideal bed utilization is between 65% and 105%. ** An excessive length of stay can be a sign that the client left the program without being discharged from HMIS. Please double-check the enrollment status of clients who are flagged under this category. Client Keys for Records with Missing and "Don't Know"/"Refused" Responses, along with Unaccompanied Children, Length-of-Stay Issues, and Invalid SSNs Missing Client General Income/ Special Key Info Benefits Needs 899208 x 239948 x x 755225 x x 1202626 x x 1203558 x x 1206229 x x 1208642 x x 1212627 x x 1213274 x x 1217471 x x 1223782 x x 1223794 x x 1225823 x x 1225840 x x 1233896 x x 1237682 x x 1237696 x x 1239985 x x 1242706 x x 1249006 x x 1255523 x x 1265783 x x 1276903 x x x 1277339 x x 1277354 x x 1278821 x x 146921 x 444945 x x 457962 x x 467094 x x 491610 x x 507049 x x 515079 x x 539926 x x 636923 x x Don't Know/Refused Destin- General Income/ Special Destination Info Benefits Needs ation x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x Miscellaneous Unacc. LoS Invalid Child Issues SSNs x Client Keys for Records with Missing and "Don't Know"/"Refused" Responses, along with Unaccompanied Children, Length-of-Stay Issues, and Invalid SSNs Missing Client General Income/ Special Key Info Benefits Needs 670764 x x 933176 x x 950037 x x 1099086 x x 1116882 x x 1125687 x x 1136436 x x 1147570 x x 1152172 x 1158277 x x 1160770 x x 1166077 x x 1173573 x x 1176809 x x 1183454 x x 1184554 x x 1194630 x x 1198287 x x 1216452 x x 1218420 x x 1225865 x x 1255534 x x 1260655 x x 1264415 x x 895504 x x 931040 x x 959994 x x 1042682 x x 1090436 x x 1126800 x x 1130764 x 1140017 x x 1158291 x x 1184757 x x 1197323 x x Don't Know/Refused Destin- General Income/ Special Destination Info Benefits Needs ation x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x Miscellaneous Unacc. LoS Invalid Child Issues SSNs x x x x x x Client Keys for Records with Missing and "Don't Know"/"Refused" Responses, along with Unaccompanied Children, Length-of-Stay Issues, and Invalid SSNs Missing Client General Income/ Special Key Info Benefits Needs 1225810 x x 1238141 x 1099069 x Don't Know/Refused Destin- General Income/ Special Destination Info Benefits Needs ation x x x x Miscellaneous Unacc. LoS Invalid Child Issues SSNs Client Keys for Records with Missing and "Don't Know"/"Refused" Responses, along with Unaccompanied Children, Length-of-Stay Issues, and Invalid SSNs Missing Don't Know/Refused Miscellaneous Client General Income/ Special Destin- General Income/ Special Destin- Unacc. LoS Invalid Key Info Benefits Needs ation Info Benefits Needs ation Child Issues SSNs Client Keys for Records with Missing and "Don't Know"/"Refused" Responses, along with Unaccompanied Children, Length-of-Stay Issues, and Invalid SSNs Missing Don't Know/Refused Miscellaneous Client General Income/ Special Destin- General Income/ Special Destin- Unacc. LoS Invalid Key Info Benefits Needs ation Info Benefits Needs ation Child Issues SSNs Client Keys for Records with Missing and "Don't Know"/"Refused" Responses, along with Unaccompanied Children, Length-of-Stay Issues, and Invalid SSNs Missing Don't Know/Refused Miscellaneous Client General Income/ Special Destin- General Income/ Special Destin- Unacc. LoS Invalid Key Info Benefits Needs ation Info Benefits Needs ation Child Issues SSNs Client Keys for Records with Missing and "Don't Know"/"Refused" Responses, along with Unaccompanied Children, Length-of-Stay Issues, and Invalid SSNs Missing Don't Know/Refused Miscellaneous Client General Income/ Special Destin- General Income/ Special Destin- Unacc. LoS Invalid Key Info Benefits Needs ation Info Benefits Needs ation Child Issues SSNs Client Keys for Records with Missing and "Don't Know"/"Refused" Responses, along with Unaccompanied Children, Length-of-Stay Issues, and Invalid SSNs Missing Don't Know/Refused Miscellaneous Client General Income/ Special Destin- General Income/ Special Destin- Unacc. LoS Invalid Key Info Benefits Needs ation Info Benefits Needs ation Child Issues SSNs Client Keys for Records with Missing and "Don't Know"/"Refused" Responses, along with Unaccompanied Children, Length-of-Stay Issues, and Invalid SSNs Missing Don't Know/Refused Miscellaneous Client General Income/ Special Destin- General Income/ Special Destin- Unacc. LoS Invalid Key Info Benefits Needs ation Info Benefits Needs ation Child Issues SSNs DCA HMIS Data Quality Report for ESG Quick Reference Guide for PATHWAYS COMPASS Corrections MISSING AND DON'T KNOW/REFUSED RESPONSES SECTION General Information Page The following fields should be corrected on the client's General Information page. First Name Last Name Social Security Number Date of Birth Race Ethnicity Gender Veteran Status Programs Page The following fields should be corrected on the client's Programs page. (Identify the Correct Program, Click the "Edit" Icon, Make corrections and Click "Save") Disabling Condition Residence Prior to Prog. Entry Zip Code of Last Permanent Address Housing Status (at entry) Destination The following Income fields should be corrected using the Finance Wizard "HERE" hyperlink (Complete the Entire Finance Wizard by making corrections and Clicking "Next" to save the information) Income (at entry) Non-Cash Benefits (at entry) Income (at exit) Non-Cash Benefits (at exit) ** Verified Dates for Income & Non-Cash Benefits need to match the Program Enrollment & Program Discharge Dates** The following Income fields should be corrected using the Finance Wizard "HERE" hyperlink (There should be a response for EVERY field, including secondary questions. Click "Save" at the bottom of the page) Physical Disability (at entry) Physical Disability (at exit) Developmental Disability (at entry) Developmental Disability (at exit) Chronic Health Condition (at entry) Chronic Health Condition (at exit) HIV/AIDS (at entry) HIV/AIDS (at exit) Mental Health (at entry) Mental Health (at exit) Substance Abuse (at entry) Substance Abuse (at exit) Domestic Violence (at entry) Domestic Violence (at exit) MISCELLANEOUS Average Bed Utilization *A very high or low bed utilization could be an indication that bed inventory is not accurate. High utilization could also be caused by a failure to discharge clients from HMIS, and low utilization could be caused by a failure to enroll clients in HMIS. The ideal bed utilization is between 65% and 105%.* If the report was run for a housing program (Emergency Shelter or Transitional Housing), please ensure that the TOTAL BEDS field reflects the number of beds within that particular program. If the amount of beds is incorrect, your PATHWAYS COMPASS Agency Administrator will need to correct your Bed & Unit Inventory for the program. From the My Agency Menu: Click Programs Identify the correct program: Click the Edit Icon Ensure that the data on the Agency Program Maintenance page is correct: Click Save 1 Bed And Unit Inventory Questionnaire: Add a record by clicking "New" OR Edit a current record by clicking the Edit Icon Excessive Length of Stay ** An excessive length of stay can be a sign that the client left the program without being discharged from HMIS. Please double-check the enrollment status of clients who are flagged under this category. Please use the additional pages of the report to identify which client keys need updated information. Generally, we expect the levels of Missing or Don't Know/Refused responses to remain below 5%. DATA CLEANING REPORTS After you have corrected all the data included on the ESG Data Quality Report, you are encouraged to run the "HUD APR Part I" to ensure that all data has been corrected and reflected on the report. Also, this report should be run monthly, as well as prior to submitting a reimbursement request. It will assist you in identifying any areas of concern (i.e. Missing or Don't Know/Refused data elements). In conjunction with the HUD APR, you should run the "Program Enrollment and Discharge" Export to identify the client records that are causing the problems. Both reports should be run for the same time periods. HUD APR From the Reports Menu: Click Statistical Categories: HUD APR Format Report: HUD APR Part I (Do Not Filter) Filter: No Enter you begin and end dates and select your program Click Run Program Enrollment & Discharge Export From Reports Menu: Click Data Export Categories: Program Information Report: PED - Program Enrollment & Discharge Enter the begin and end dates Click Run **With this report, it includes all client records that were enrolled and/or discharged from any program within your agency during the time period you entered. If you have more than one program, you may want to Sort or Filter the report by the program name. For any questions related to ESG HMIS grant requirements, you can refer to the Exhibit E in your contract. You can also find the DCA ESG HMIS policy and data requirements on the DCA ESG Grantees Only webpage (link below). If these resources do not address your questions, please email Christy Hahn (Emergency Solutions Grant Coordinator) at christy.hahn@dca.ga.gov. For assistance with the regarding your ESG-funded programs on the PATHWAYS COMPASS system, please contact April Lockett (Emergency Solutions Grant TA Specialist) at april.lockett@pcni.org. http://www.dca.state.ga.us/housing/specialneeds/programs/ESGGranteesOnly.asp 2 LEASE BASIC RENTAL AGREEMENT OR RESIDENTIAL LEASE This Rental Agreement or Residential Lease shall evidence the complete terms and conditions under which the parties whose signatures appear below have agreed. Landlord/Lessor/Agent, _____________________________, shall be referred to as "OWNER" and Tenant(s)/Lessee, _____________________________, shall be referred to as "RESIDENT." As consideration for this agreement, OWNER agrees to rent/lease to RESIDENT and RESIDENT agrees to rent/lease from OWNER for use solely as a private residence, the premises located at _____________________________________________in the city of __________________________________. 1. TERMS: RESIDENT agrees to pay in advance $______ per month on the ____ day of each month. This agreement shall commence on _____,___ and continue; (check one) A.__ until _______, ___ as a leasehold. Thereafter it shall become a month-to-month tenancy. If RESIDENT should move from the premises prior to the expiration of this time period, he shall be liable for all rent due until such time that the Residence is occupied by an OWNER approved paying RESIDENT and/or expiration of said time period, whichever is shorter. B.__ until ____________, ______ on a month-to-month tenancy until either party shall terminate this agreement by giving a written notice of intention to terminate at least 30 days prior to the date of termination. 2. PAYMENTS: Rent and/or other charges are to be paid at such place or method designated by the owner as follows _____________________________________. All payments are to be made by check or money order and cash shall be acceptable. OWNER acknowledges receipt of the First Month's rent of $__________, and a Security Deposit of $__________, and additional charges/fees for ______________________________, for a total payment of $__________. All payments are to be made payable to __________________________________. 3. SECURITY DEPOSITS: The total of the above deposits shall secure compliance with the terms and conditions of this agreement and shall be refunded to RESIDENT within _____ days after the premises have been completely vacated less any amount necessary to pay OWNER; a) any unpaid rent, b) cleaning costs, c) key replacement costs, d) cost for repair of damages to premises and/or common areas above ordinary wear and tear, and e) any other amount legally allowable under the terms of this agreement. A written accounting of said charges shall be presented to RESIDENT within _____ days of move-out. If deposits do not cover such costs and damages, the RESIDENT shall immediately pay said additional costs for damages to OWNER. 4. LATE CHARGE: A late fee of $_____, (not to exceed ___% of the monthly rent), shall be added and due for any payment of rent made after the ____________ of the month. Any dishonored check shall be treated as unpaid rent, and subject to an additional fee of $_________. 5. UTILITIES: RESIDENT agrees to pay all utilities and/or services based upon occupancy of the premises except ____________________________________. 6. OCCUPANTS: Guest(s) staying over 15 days without the written consent of OWNER shall be considered a breach of this agreement. ONLY the following individuals and/or animals, AND NO OTHERS shall occupy the subject residence for more than 15 days unless the expressed written consent of OWNER obtained in advance __________________________________________________. 7. PETS: No animal, fowl, fish, reptile, and/or pet of any kind shall be kept on or about the premises, for any amount of time, without obtaining the prior written consent and meeting the requirements of the OWNER. Such consent if granted, shall be revocable at OWNER'S option upon giving a 30 day written notice. In the event laws are passed or permission is granted to have a pet and/or animal of any kind, an additional deposit in the amount of $_________ shall be required along with additional monthly rent of $_______ along with the signing of OWNER'S Pet Agreement. RESIDENT also agrees to carry insurance deemed appropriate by OWNER to cover possible liability and damages that may be caused by such animals. 8. LIQUID FILLED FURNISHINGS: No liquid filled furniture, receptacle containing more than ten gallons of liquid is permitted without prior written consent and meeting the requirements of the OWNER. RESIDENT also agrees to carry insurance deemed appropriate by OWNER to cover possible losses that may be caused by such items. 9. PARKING: When and if RESIDENT is assigned a parking area/space on OWNER'S property, the parking area/space shall be used exclusively for parking of passenger automobiles and/or those approved vehicles listed on RESIDENT'S Application attached hereto. RESIDENT is hereby assigned or permitted to park only in the following area or space ____________________________. The parking fee for this space (if applicable is $________ monthly. Said space shall not be used for the washing, painting, or repair of vehicles. No other parking space shall be used by RESIDENT or RESIDENT'S guest(s). RESIDENT is responsible for oil leaks and other vehicle discharges for which RESIDENT shall be charged for cleaning if deemed necessary by OWNER. 10. NOISE: RESIDENT agrees not to cause or allow any noise or activity on the premises which might disturb the peace and quiet of another RESIDENT and/or neighbor. Said noise and/or activity shall be a breach of this agreement. 11. DESTRUCTION OF PREMISES: If the premises become totally or partially destroyed during the term of this Agreement so that RESIDENT'S use is seriously impaired, OWNER or RESIDENT may terminate this Agreement immediately upon three day written notice to the other. 12. CONDITION OF PREMISES: RESIDENT acknowledges that he has examined the premises and that said premises, all furnishings, fixtures, furniture, plumbing, heating, electrical facilities, all items listed on the attached property condition checklist, if any, and/or all other items provided by OWNER are all clean, and in good satisfactory condition except as may be indicated elsewhere in this Agreement. RESIDENT agrees to keep the premises and all items in good order and good condition and to immediately pay for costs to repair and/or replace any portion of the above damaged by RESIDENT, his guests and/or invitees, except as provided by law. At the termination of this Agreement, all of above items in this provision shall be returned to OWNER in clean and good condition except for reasonable wear and tear and the premises shall be free of all personal property and trash not belonging to OWNER. It is agreed that all dirt, holes, tears, burns, and stains of any size or amount in the carpets, drapes, walls, fixtures, and/or any other part of the premises, do not constitute reasonable wear and tear. 13. ALTERATIONS: RESIDENT shall not paint, wallpaper, alter or redecorate, change or install locks, install antenna or other equipment, screws, fastening devices, large nails, or adhesive materials, place signs, displays, or other exhibits, on or in any portion of the premises without the written consent of the OWNER except as may be provided by law. 14: PROPERTY MAINTENANCE: RESIDENT shall deposit all garbage and waste in a clean and sanitary manner into the proper receptacles and shall cooperate in keeping the garbage area neat and clean. RESIDENT shall be responsible for disposing of items of such size and nature as are not normally acceptable by the garbage hauler. RESIDENT shall be responsible for keeping the kitchen and bathroom drains free of things that may tend to cause clogging of the drains. RESIDENT shall pay for the cleaning out of any plumbing fixture that may need to be cleared of stoppage and for the expense or damage caused by stopping of waste pipes or overflow from bathtubs, wash basins, or sinks. 15. HOUSE RULES: RESIDENT shall comply with all house rules as stated on separate addendum, but which are deemed part of this rental agreement, and a violation of any of the house rules is considered a breach of this agreement. 16. CHANGE OF TERMS: The terms and conditions of this agreement are subject to future change by OWNER after the expiration of the agreed lease period upon 30-day written notice setting forth such change and delivered to RESIDENT. Any changes are subject to laws in existence at the time of the Notice of Change Of Terms. 17. TERMINATION: After expiration of the leasing period, this agreement is automatically renewed from month to month, but may be terminated by either party giving to the other a 30-day written notice of intention to terminate. Where laws require "just cause", such just cause shall be so stated on said notice. The premises shall be considered vacated only after all areas including storage areas are clear of all RESIDENT'S belongings, and keys and other property furnished for RESIDENT'S use are returned to OWNER. Should the RESIDENT hold over beyond the termination date or fail to vacate all possessions on or before the termination date, RESIDENT shall be liable for additional rent and damages which may include damages due to OWNER'S loss of prospective new renters. 18. POSSESSION: If OWNER is unable to deliver possession of the residence to RESIDENTS on the agreed date, because of the loss or destruction of the residence or because of the failure of the prior residents to vacate or for any other reason, the RESIDENT and/or OWNER may immediately cancel and terminate this agreement upon written notice to the other party at their last known address, whereupon neither party shall have liability to the other, and any sums paid under this Agreement shall be refunded in full. If neither party cancels, this Agreement shall be prorated and begin on the date of actual possession. 19. INSURANCE: RESIDENT acknowledges that OWNERS insurance does not cover personal property damage caused by fire, theft, rain, war, acts of God, acts of others, and/or any other causes, nor shall OWNER be held liable for such losses. RESIDENT is hereby advised to obtain his own insurance policy to cover any personal losses. 20. RIGHT OF ENTRY AND INSPECTION: OWNER may enter, inspect, and/or repair the premises at any time in case of emergency or suspected abandonment. OWNER shall give 24 hours advance notice and may enter for the purpose of showing the premises during normal business hours to prospective renters, buyers, lenders, for smoke alarm inspections, and/or for normal inspections and repairs. OWNER is permitted to make all alterations, repairs and maintenance that in OWNER'S judgment is necessary to perform. 21. ASSIGNMENT: RESIDENT agrees not to transfer, assign or sublet the premises or any part thereof. 22. PARTIAL INVALIDITY: Nothing contained in this Agreement shall be construed as waiving any of the OWNER'S or RESIDENT'S rights under the law. If any part of this Agreement shall be in conflict with the law, that part shall be void to the extent that it is in conflict, but shall not invalidate this Agreement nor shall it affect the validity or enforceability of any other provision of this Agreement. 22. NO WAIVER: OWNER'S acceptance of rent with knowledge of any default by RESIDENT or waiver by OWNER of any breach of any term of this Agreement shall not constitute a waiver of subsequent breaches. Failure to require compliance or to exercise any right shall not be constituted as a waiver by OWNER of said term, condition, and/or right, and shall not affect the validity or enforceability of any provision of this Agreement. 23. ATTORNEY FEES: If any legal action or proceedings be brought by either party of this Agreement, the prevailing party shall be reimbursed for all reasonable attorney's fees and costs in addition to other damages awarded. 24. JOINTLY AND SEVERALLY: The undersigned RESIDENTS are jointly and severally responsible and liable for all obligations under this agreement. 25. REPORT TO CREDIT/TENANT AGENCIES: You are hereby notified that a nonpayment, late payment or breach of any of the terms of this rental agreement may be submitted/reported to a credit and/or tenant reporting agency, and may create a negative credit record on your credit report. 26. LEAD NOTIFICATION REQUIREMENT: For rental dwellings built before 1978, RESIDENT acknowledges receipt of the following: (Please check) ___ Lead Based Paint Disclosure Form ___ EPA Pamphlet 27. ADDITIONS AND/OR EXCEPTIONS _______________________________________________________________ _______________________________________________________________. 28. NOTICES: All notices to RESIDENT shall be served at RESIDENT'S premises and all notices to OWNER shall be served at _______________________________________________________________. 29. INVENTORY: The premises contains the following items, that the RESIDENT may use. _______________________________________________________________. 30. KEYS AND ADDDENDUMS: RESIDENT acknowledges receipt of the following which shall be deemed part of this Agreement: (Please check) ___ Keys #of keys and purposes ___________________________________________ ___ House Rules ___ Pet Agreement ___ Other ________________________________ 31. ENTIRE AGREEMENT: This Agreement constitutes the entire Agreement between OWNER and RESIDENT. No oral agreements have been entered into, and all modifications or notices shall be in writing to be valid. 32. RECEIPT OF AGREEMENT: The undersigned RESIDENTS have read and understand this Agreement and hereby acknowledge receipt of a copy of this Rental Agreement. RESIDENT'S Signature ___________________________________________________ Date__________________ RESIDENT'S Signature ___________________________________________________ Date__________________ OWNER'S or Agent's Signature ____________________________________________ Date__________________ SAMPLE POLICIES #1 SAMPLE POLICY FOR Termination, Complaints, Appeals, Confidentiality A letter detailing the reason for the appeal and any evidence that backs the participant's claim is to be mailed to the ESG Grievance officer within three business days of receiving the notice. The Grievance Office will review the information and evidence presented to ensure the participant has been treated fairly and in compliance with program guidelines. lf the Grievance Officer determines that the participant was treated unfairly and should be allowed to enroll or continue assistance through the program, the client will be notified by mail within one week of receipt of the appeal letter and the caseworker will be notified of the decision. lf the decision to terminate/deny is upheld, the client will be notified in writing within one week of receipt of the appeal letter and the caseworker will be notified of the decision. In accordance with Federal law and U .S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. Assistance will be provided to those with disabilities upon request to ensure that equal access to an appeal is available. Complaints A letter detailing the reason for the complainant and any evidence that backs the participant's claim is to be mailed to the ESG Grievance Officer within days of the event in question. The Grievance Officer will review the information and evidence presented and consult with the Director as necessary. lf it is determined that the participant was treated unfairly, the Grievance Officer the client will be notified by mail within one week of receipt of the complaint. lf necessary the complaining party will be contacted concerning the progress of the resolution. Contact information for the Grievance Officer is provided on the Client Information Handout. A Fair Hearing Poster in each outreach office provides contact information for the Program Director for complaint purposes. If a complaint provides sufficient evidence that any agency policy or procedure is questionable, a review of the policy/policies will be conducted by the Program Director and a designee of his/her choosing. This institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. Assistance will be provided to those with disabilities upon request to ensure that equal access to an appeal is available. Confidentiality Information relating to family information files are to be kept in a locked file at all times. 1 When specific files are in direct use, these files will not be left unattended and will be returned to a locked file upon completion of use. The Program Director and/or designee will have access to file keys. Family information files will not be removed from t he premises at anytime unless otherwise quested by the Executive Director or designee. Family information can only be released to other person/agencies with written informed consent of client. Written informed consent must specify the information to be released. Family information will be discussed only with staff members that are directly concerned or involved with the delivery of services to the family. Unauthorized persons will not have access to files at any time. Family information data can only be accessed in direct relationship with service delivery unless otherwise authorized by a direct supervisor, primary case manager or training and technical advisor. Information will not be copied, printed, or shared except for the sole purpose of service delivery. Altering client information without approval is a violation and will result in termination. Client files must be maintained in a secure area for a minimum of five (5) years. After five (5) years, the files must be destroyed by shredding or burning. Clients will have access to their family files upon request. Volunteers will be trained on procedures for maintaining client confidentiality. Only general program information will be released without written consent (i .e. number of children with disabilities, compiled data about a family, enrollment numbers etc.). General information DOES NOT pertain to a specific family. Any staff person who fails to maintain confidentiality relating to families and fellow staff members, will be disciplined as deemed appropriate, up to and including termination of employment. Clients should be aware that they have the right to make a complaint if they feel that their confidentiality has been breached unnecessarily or maliciously. Staff should encourage clients to make a formal complaint and they should assist the client in the following procedure as appropriate. "Need to Know" Information obtained must be necessary in order to conduct assigned job duties and responsibilities including, but not limited to, the following to determining eligibility: providing training providing treatment for or contributing to the diagnosis of any medical or physiological illness, injury ,or condition assessing financial ability paying any financial obligation initiating or furthering any investigatory, regulatory, or enforcement purpose providing any service 2 EQUINOX COMPLAINTS POLICY #2 SAMPLE COMPLAINTS POLICY INTRODUCTION 1.1 Equinox seeks to provide the best possible service to its service users, partners and the community as a whole. Part of this involves a response to any complaints, issues or problems that may occur. The complaints policy exists as a framework to ensure that each problem is dealt with sensitively, quickly and fairly. 1.2 Complaints may come from a number of sources, and be relating to policy and procedure, service users, staff, or a management decision. All should be taken seriously, as they provide a chance to evaluate, test and examine our services. 1.3 Equinox has a duty to its stakeholders to ensure that complaints are carefully recorded, and as an organisation, we are accountable for the services we provide. 1.4 Complaints may come in a variety of ways, and will differ in how they are presented, and in their seriousness. This policy will detail the differing ways in which they are dealt with. 1.0 UNOFFICIAL COMPLAINTS 2.1 When a complainant wishes to complain verbally in an unofficial capacity, this may be dealt with by a project worker, or manager. (The project worker will be expected to assess at this stage, whether the complaint is serious enough to warrant a manager dealing with it, or whether it can be managed unofficially.) Often this type of complaint will elicit a quick response, which will be able to be dealt with immediately, and will not need an investigation. If dealt with by a project worker, this should be written up and passed on to the service manager at the first available opportunity. 2.2 It is important that the project worker offers the complainant the option of making a formal complaint, during the unofficial process. If the complainant wishes the complaint to become formal, then the project worker should encourage the complainant to put this down in writing, using the complaint form attached (see Appendix 1). The project worker should inform their line manager of the situation, and write up any necessary information. 2.3 All services are required to ensure that they have a means of recording all complaints of an unofficial and official nature (e.g. through use of a record book) and regardless of status all complaints must be reported as part of the Equinox management information system and dealt with in line with agreed standards. 2.0 MAKING A COMPLAINT 3 3.1 The complaints policy & form will be made available to all service users, and to anyone wishing to have a copy. The policy will be placed in the welcome pack for residential services or other relevant service specific information packs. The complaints form will also be displayed in communal areas of projects, as appropriate. 3.2 Equinox recognizes that some service users may not be used to making complaints in this way. Some people may also have difficulties in filling in forms. Where a staff member is aware that a complainant may find the process difficult, they should offer to assist the complainant in making the complaint. They should also explain that the complainant may ask for someone else to assist them in making the complaint, if that member of staff is not appropriate. 3.3 Each service should also have a list of external agencies where a service user may find someone externally to advocate on their behalf. This list will be included in welcome packs, and displayed within the project. 3.4 Some complaints are made over problems that Equinox has no control over, e.g. maintenance done by a partner RSL. In these cases, the complainant should be made aware that Equinox has no control over the situation. Staff will encourage the complainant to complain to the right agency, and support and advocate on their behalf as appropriate. 4.0 THE COMPLAINTS PROCESS 4.1 When a complaint is made staff should always inform their line manager. If s/he is not available, then they should contact another manager within the service. The staff member should fax or email a copy of the complaint to them immediately. 4.2 Managers should then investigate the complaint. Because of the tight timescale involved in responding to the complaint (5 working days), managers will have to re-prioritize their work, in order to give the investigation enough time. 4.3 An investigation will potentially involve a meeting with the person who has complained, as well as any third party involved with the situation. The manager will consider all views, before making their decision. The manager's decision will be communicated in writing to all parties immediately. Where possible a personal meeting should be offered to explain the decision taken. 4.4 Service Managers must ensure that they report all complaints to partner agencies and commissioners as required including Supporting People Teams, CSCI and partner Housing Associations. 4.5 The complainant should be informed at this point that if they are unhappy with the decision that they may appeal to the Operations Director. 4.6 The Operations Director will hear all appeals under the same conditions that governed the original decision. They will wherever possible, respond to the complaint within 5 working days, and will undertake as appropriate, to meet with the complainant, as well as the manager who made the initial decision. The Operations Director's decision will be considered final within Equinox. 4 4.7 The complainant will be informed that if they wish to appeal against this decision, they may be able to appeal to an external organization. This would include CSCI, ombudsman, a partner RSL, or a funder, as appropriate. Details will be given to the complainant, at this time, as appropriate. 5.0 OTHER PRINCIPLES 5.1 Equinox strives to be a responsible service provider and as such will treat seriously complaints received from relatives of service users, neighbors and significant others. These complaints will be dealt with using this framework though for the purposes of monitoring recorded distinctly on reports to Management Committee. 5.2 The Management Committee will set performance targets for the response to complaints and actively monitor performance in this area. 5.3 It is the responsibility of all staff within equinox to treat complaints seriously and to seek to resolve issues sensitively. It is the responsibility of Service Managers to ensure that this policy is fully implemented. Reviewed: March 2006 (Next Review: March 2008) 5 #3 SAMPLE CONFIDENTIALITY POLICY Equinox Tenancy Support Service Confidentiality Policy Equinox TSS operates an open file system, allowing tenants access to their files, and to any information that Equinox holds concerning them. Any tenant wishing to examine their file, should approach their housing support worker who will arrange a convenient time at both persons convenience. Whilst reasonable notice should be given, the worker should endeavour where possible to arrange the meeting within 24 hours of the request. The tenant may examine any of the written information within the file. They should also be offered assistance in understanding what is in there. They may also make photocopies of the file for their personal use. However the file remains the property of Equinox and should not be taken away from the office. If information is needed from another agency, written permission should be obtained from the tenant and this should be faxed or posted to the agency, along with the request. Any information concerning the tenant will not normally be given without written permission from the tenant. Information may be given out to a third party under the following circumstances: The member of staff believes that the tenant is a serious danger to either themselves, others or property. The member of staff should contact the TSS manager to gain permission to release the information. If the TSS manager is not available, they should talk to an alternative Equinox manager. Failing this, they should agree it with a colleague before releasing the information. They should inform the third party that this is an exceptional case, and ask them to respect the circumstances in which they are giving the information out, and that the information should not be passed on without the tenants and / or Equinox's consent. 6 If a request for information is received from a press source, they should be referred to the Operations Director who deals with all external press enquiries. On no account, should anyone else give information out. If a third party sends information concerning a tenant but instructs that they should not see it the following procedure should be adhered to: A note should be placed in the file informing that the information has been received. A separate file should be started, with the relevant document stored within it. The file should be marked Confidential Staff only. This should be locked away separately. If workers are unsure of the circumstances concerning either of the above procedures, or any other potential conflict of interest they should seek guidance from a manager before taking any action. Tenant Appeals Procedure Tenants should be aware that they have the right to make a complaint if they feel that their confidentiality has been breached unnecessarily, or maliciously. Staff should encourage tenants to make a formal complaint and as appropriate, they should assist the tenant in following the complaints procedure. If the staff member has breached confidentiality, they should address their complaint to the service manager, however if the service manager has made the original decision they can complain direct to the Operations Director. Last reviewed May 2004 Next review May 2005 7 PATH Peers Project A Street to Home Initiative VULNERABILITY INDEX INTERVIEWER'S NAME:______________________________ DATE:_______________________ LOCATION:_________________________________________ TIME:_______________________ FIRST NAME:____________________________ LAST NAME:_______________________________ DOB:____________________SS#:_______________________TELEPHONE:____________________ WHERE DID YOU SLEEP LAST NIGHT:___________________________________________________ HAS CONSENTED TO PARTICIPATE: YES NO AGREE TO HAVE PHOTOGRAPH: YES NO KEEP THIS DOCUMENT IN ACCORDANCE WITH CONFIDENTIALITY PROCEDURES Page 1 of 4 PATH Peers Project A Street to Home Initiative VULNERABILITY INDEX What is the total length of time you have been homeless? Years___________ Months_____________ Where do you sleep most frequently? (Check only one) Shelters Streets Car/Van Subway/bus Other________________ Where did you live prior to becoming homeless? (Check only one) Atlanta Metro Atlanta Georgia Other (specify)____________________ Where do you usually go for health care or when you are not feeling well? Grady Hospital Emergency St. Joseph's Mercy Care Crawford Long Hospital Emory Hospital Other (specify)____________________ Does not go for care **TB TEST SCHEDULED/COMPLETED**....................................... Yes No Result:________________________________________________________ How many times have you been to the emergency room in the past 3 months?___________________ How many times have you been hospitalized as an inpatient in the past year?____________________ Do you now have, ever had, or have been told by a healthcare provider you have any of the following: a. Kidney Disease/End Stage Renal Disease or Dialysis......... b. History of frostbite, Hypothermia, or immersion Foot..... c. History of Heat Stroke/Heat Exhaustion............................. d. Liver Disease, Cirrhosis, or End Stage Liver Disease.......... e. Heart Disease, Arrhythmia, or irregular Heartbeat........... f. HIV+/AIDS................................................................................. g. Emphysema.............................................................................. h. Diabetes.................................................................................... i. Asthma...................................................................................... j. Cancer........................................................................................ k. Hepatitis C.................................................................................. l. Tuberculosis.............................................................................. Yes No Refused Yes No Refused Yes No Refused Yes No Refused Yes No Refused Yes No Refused Yes No Refused Yes No Refused Yes No Refused Yes No Refused Yes No Refused Yes No Refused DO NOT ASK: Do you see any signs or symptoms of a serious physical health condition? .................................................................................................... Yes No Page 2 of 4 PATH Peers Project A Street to Home Initiative VULNERABILITY INDEX m. Have you ever abused drugs/alcohol, or been told you do?......... n. Have you consumed alcohol every day for the past month?........ o. Have you ever used injection drugs?.............................................. p. Have you ever been treated for drug or alcohol abuse?................ q. DO NOT ASK: Do you see signs or symptoms of abuse?............... Yes No Refused Yes No Refused Yes No Refused Yes No Refused Yes No Refused r. Are you currently or have you ever been treated for mental health issues? ................................................................................................. Yes No Refused s. Have you ever been taken to the hospital against your will for mental health reasons? ........................................................................................................... Yes No Refused t. DO NOT ASK: Do you detect signs or symptoms of mental health issues? ........................................................................................................... Yes No Refused u. Do you have a mental health diagnosis?........................................... Yes No Refused (specify)_________________________________________________________________ v. Are you taking any mental health medications?............................... Yes No Refused (specify)_________________________________________________________________ w. Have you seen a mental health professional?................................... Yes No Refused (when/where)_________________________________________________________________ x. Have you been the victim of a violent attack?.................................... Yes No Refused y. Do you have a physical disability that limits your mobility?............... Yes No Refused (specify)_________________________________________________________________ z. Have you had a serious brain injury that required hospitalization?...... Yes No Refused (specify)_________________________________________________________________ What kind of medical insurance do you have? Medicaid Medicare VA Private None Other_______________ Page 3 of 4 PATH Peers Project A Street to Home Initiative VULNERABILITY INDEX Have you ever served in the military?............................................................ Yes No Refused If yes, what was the nature of your discharge?................................................................................. Honorable Other than Honorable Bad Conduct Dishonorable Have you ever been in jail? .................................................................................. Yes No Refused Have you ever been in prison? ................................................................... Yes No Refused Have you ever been in foster care? ................................................................... Yes No Refused How do you make money: Work Food Stamps SSI SSDI/SSA VA Amount:_________________________________ None What is your gender? Male Female Transgender What is your ethnicity? African American Asian White Native American Mixed Race Declined to state Declined to State Latino/a Native Hawaiian/Pacific Islander Unknown What is your citizenship status? Citizen Legal Resident Undocumented What is the highest grade in school you completed? K8 Some high school High school graduate Some College College Graduate Post Graduate GED Other Page 4 of 4