Staffcertificationof Eligibility Forhcrp Assistance

HCRPCustomer Enrollment

STAFFCERTIFICATIONOF ELIGIBILITY FORHCRP ASSISTANCE

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

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

*All members inhousehold thatwill benefit fromHCRPassistanceshould belistedhere.

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

HCRP Staff Signature: Date:

HCRP Supervisor Signature: Date:

HCRP offersrapid re-housing for individuals/families experiencing homelessness. A subsidy will be provided to the family to avoid homelessness, and the family agrees to participate in, monthly appointments. The purpose of this agreement is to state the terms and conditions under which the HCRP funds and supportive services are to be provided to program participants and provisions of termination of assistance. By signing this agreement, I, ______understand the following:

Tenant/Family Responsibilities/Obligations

1. I understand this assistance is TEMPORARY and I must develop an Individualized Service Plan (ISP) to transition off assistance within 3 months.

2. I will work toward my exit strategy goal and understand that if I fail to meet with my Case Manger every 30 days, I will be removed from the HCRP Program.

3. I will pay my portionof the rent. I understand that I need to report any changes of income (up or down) to HCRP within 10 days of receiving any change of income. I understand that I will need to pay my portion of the rent and utility bills and this is a major responsibility of this program - failure to pay the rent, utility bills, on time may lead to termination of my participation in the HCRP.
4. I understand the unit must be my only residence. I understand I/members of my family may not receive other housing/utility subsidies for any housing unit under any duplicative Federal, State, or local subsidy program. I understand that I cannot sub-lease/let/transfer lease to another household.

5. I will allow HCRP to meet with my family every 30 days in the unit at reasonable times. I understand that I will need to meet with HCRPstaff to review my exit strategy. I understand that I must notify staff if I have a conflict with an appointment time. I understand that if I miss an appointment, HCRP Staff is REQUIRED by their funders to notify my landlord and terminate my assistance within 24 hours.

6. I will follow all aspects of the lease - I will not commit any serious or repeated violation of the lease or damage the unit or permit any household member/guest to damage the unit. Damage is understood to be any damage other than ordinary wear and tear. I understand that I must keep my unit clean and sanitary. I will be respectful of neighbor’s right to a peaceful environment.

7. I understand I/members of my family must not commit fraud, bribery, or illegal/violent acts including drug related activities in the unit or on the property. I understand that if my unit is vacant due to my incarceration, I will no longer be eligible for HCRP.

8. I will report to the landlord or building staff any problems with plumbing, lights, appliances, air conditioning, heating, etc.

9. I understand that my participation in the program must be re-determined every 90 days. My recertification date is ______. I understand that if I do not provide required documentation and recertify by this date my participation in the program is automatically terminated.

Termination of Assistance

If the participant violates HCRP requirements and/or this agreement, the program may recommend ending the rental/utility assistance for the participant. The termination processmay include, but is not limited to:

1. Written notice to the participant detailing reasons for termination:
2. Not following program requirements or agreement
3. Participant request to withdraw from HCRP
4. Notification of landlord of the reason for termination

If I do not agree with the reasons for termination I may follow the grievance process:

Grievance Process

There are three (3) steps to the grievance process:

1. Discuss the matter with a staff member involved. Frank discussion will usually clear up the misunderstanding and solve the problem. If the matter remains unresolved, go to the next step.

2. Request a complaint form and complete it. Forward the report to the HCRP DirectorSteve Creed, 1400 U.S. Route 22 NW Washington Court House, OH 43160. If you are unable to fill out the complaint form, you may request a meeting with the HCRP Director. She/He will review the complaint and respond in writing to the participant within five (5) working days of receipt of the report. If the participant remains dissatisfied with the resolution offered, she/he may take the next step. ** Or in the case that the grievance is with the HCRP Director move to step 3.

3. Request that the complaint form be forwarded to the Executive Director for review. She/He will take one of the following two (2) steps:

• Give the participant a written response which would indicate the final disposition; or
• Call a conference for the parties involved in the incident(s). The final disposition will be issued within five (5) working days of the conference.

If the decision is not satisfactory, you may file a request for an administrative appeal. Submit your written appeal, along with the response of the agency to Kim Alexanderat 77 S. High Street, P.O. Box 1001 Columbus, OH 43216.

______
Head of Household Signature Date
(Provide copy to Head of Household)

HCRP Confidentiality Agreement

Confidentiality is protecting another person’s right to privacy
In order for HCRP customers to have trust in their relationship with Case Managers, it is important for customers to know that the information they reveal to an employee will not be discussed with anyone else. This means that an employee will not reveal a resident’s personal information to anyone, including other customers or one’s family, without a resident’s written permission, unless required by law.

A Release of Information form is used to obtain this permission between the Service Coordinator and customer. This Confidentiality Agreement form serves as the permission between the Case Manager and customer to allow Case Managers to meet, get acquainted, and discuss social and personal interests that a resident reveals with other community and social service providers and program evaluators.

Exceptions to the Right of Confidentiality
Case Managers are asked to report information to the Coordinator that is required by Federal or state law. This includes information that indicates a customer is endangered or exploited, or information that is related to suspected fraudulent activity or other violations of the law.

Confidentiality Pledge
As your Case Manager, I agree to protect your right to privacy and confidentiality. I will not disclose any information about you without your written permission unless I am required to do so by law or authorized to do so by your signed release.

Case Manager Signature Date

Resident Signature Date

(A copy of this form is placed in the client’s file. The original is given to the client.)

TAB 2 – ENROLLMENT CHECKLIST