HomeMy WebLinkAboutAgreement A-15-210 MOU with Housing Authority.pdfAgreement No.15-210
1 MEMORANDUM OF UNDERSTANDING
2 Between the County of Fresno
3 And
4 Housing Authority of the City and County of Fresno .
5 TIDS MEMORANDUM OF UNDERSTANDING, hereinafter referred to as "MOll" or
6 "Agreement" is made and entered into this 2nd day of ___ .=.;Ju=.:..n;.;:;e ___ ___. 2015, between
7 the COUNTY OF FRESNO, a Political Subdivision ofthe State of California, hereinafter referred to
8 as "COUNTY," and HOUSING AUTHORITY OF THE CITY AND COUNTY OF FRESNO
9 hereinafter referred to as "HACCF," whose address is 1331 Fulton Mall, P.O. Box 11985, Fresno,
10 CA 93776.
11 WITNESSETH:
12 WHEREAS, the Shelter Plus Care (SPC) Tenant-based Rental Assistance (TRA)
13 Program is funded by Subtitle C, Section 421 Continuum of Care Program of the Stewart B.
14 McKinney Homeless Assistance Act as amended by S. 896, The Homeless Emergency Assistance
15 and Rapid Transition to Housing (HEARTH) Act of 2009; and
16 WHEREAS, SPC TRA program provides tenant based rental assistance and
17 supportive services to disabled homeless individuals/families with serious mental health issues;
18 chronic substance use disorder; HIV and/or related diseases; physical health issues and/or
19 developmental disabilities; and
20 WHEREAS, HACCF has agreed to set aside fifty one (51) SPC certificates for the
21 COUNTY's Department of Behavioral Health (DBH) and its select HACCFs; and
22 WHEREAS, COUNTY's DBH and its select HACCFs have expressed commi1ment
23 to providing supportive services for the referred SPC participants under such certificates; and
24 WHEREAS, it is to the mutual benefit of the parties hereto that HACCF and
25 COUNTY's DBH and its select HACCFs collaborate for the provision of SPC 1RA program
26 services to aid disabled homeless individuals and families with serious mental health issues;
27 chronic substance use disorder; HIV and/or related diseases; physical health issues and/or
28 developmental disabilities; and
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1 WHEREAS, the purpose of this MOU is to clearly identify the roles and
2 responsibilities of the HACCF and COUNTY;
3 NOW, THEREFORE, the parties agree as follows:
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1. BESPONSIBILITIES OF THE UACCF
HACCF shall:
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c.
Administer the SPC program in compliance with applicable regulations.
Coordinate and facilitate monthly round table meetings.
Based on SPC program availability, submit written requests to
9 COUNTY's designated DBH staff for referrals through the Coordinated Entry Housing
10 Placement system.
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Coordinate SPC participant intake.
Compile quarterly SPC data and reports on Homeless Management
13 Information System (HMIS).
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Provide technical assistance and training to DBH designated staff as
Assist SPC participants to retain housing r e n t a I assistance.
Conduct owner outreach for SPC participants.
Provide eligibility/annual re-certifications and Housing Quality Standards
19 Inspections for SPC participants.
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J. Conduct quarterly site visits with DBH designated staff to ensure program
compliance.
K. Monitor and update monthly reports for COUNTY's in-kind supportive
services match.
L. Identify a HACCF staff as a liaison between HACCF and the
COUNTY.
M. Process SPC participant termination for non-compliance with SPC Program
regulations, including non-compliance with Participant-Service Provider Agreements.
II
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2. BESPONSIBILITIES OF TBE COUNTY
COUNTY and its select HACCFs shall:
A. Provide SPC program outreach to eligible hard to reach persons (e.g. living
4 on the street or in an emergency shelter).
5 B. Refer eligible homeless and disabled individuals/families to SPC program
6 through Coordinated Entry Housing Placement system.
7 c. Upon COUNTY'S receipt in writing of SPC program availability from
8 HACCF designated staff, COUNTY and its select HACCFs shall submit the allocated referrals
9 within thirty (30) days to the Coordinated Entry Housing Placement system. If unable to fill the
10 allocated referrals, the HACCF has the right to accept referrals from other service providers, which
11 will assume all cash match reporting responsibilities for the SPC participant referred.
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D. Provide a minimum of One Hundred Eighty (180) days' notice to HACCF
prior to discontinuation of supportive services.
E. Complete the following forms:
1) Shelter Plus Care Tenant-Based Rental Assistance Referral form, as
identified in Exhibit A, attached hereto and by this reference incorporated herein.
2) Certification of Disability form, as identified in Exhibit B, attached
hereto and by this reference incorporated herein.
3) Homeless Certification form and Chronically Homeless form with
proper documentation as identified in Exhibit C and Exhibit D respectively, attached hereto and by
this reference incorporated herein.
4) Participant-Service Provider Agreement as identified in Exhibit E,
attached hereto and by this reference incorporated herein.
5) Release of Information as identified in Exhibit F, attached hereto and by
26 this reference incorporated herein.
27 6) Homeless Management Information System (HMIS) Data Collection as
28 identified in Exhibit G, attached hereto and by this reference incorporated herein.
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7) HMIS Release of Information as identified in Exhibit H, attached hereto
and by this reference incorporated herein.
8) Application for Initial Occupancy as identified in Exhibit I, attached
hereto and by this reference incorporated herein.
Each form is to be completed as per the instructions on the respective form and
in conformance to SPC Program Regulations. COUNTY and its select HACCFs shall provide and
attach all necessary supporting documentation as indicated within each form to HACCF's
designated staff.
F. Provide confidential on-going case management and/or supportive services to
SPC participants. The parties agree that supportive services provided by COUNTY and its selected
HACCFs may be in the form of treatment, therapy, crisis intervention, medication support,
residential treatment, inpatient psychiatric care, vocational rehabilitation, mental health services and
other services mutually agreed to be considered supportive services. The parties agree that the
HACCF shall make the fmal determination of whether a service is considered a supportive service.
G. Maintain SPC participant file with accurate documentation of supportive
services match, an Individual Service Plan (ISP), case notes, and any other documents deemed
necessary to meet the SPC Program requirements.
H. Maintain a copy of the initial ISP, and a copy of the updated ISP thereafter in
the SPC participant file.
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J.
Attend the monthly collaborative round table meetings.
Ensure supportive services are equivalent to or in excess of25% of the
amount paid inSPC Rental Assistance Payment (RAP) by HACCF each operating month and year,
for all SPC participants referred by COUNTY. COUNTY and its select HACCFs shall ensure that
each SPC TRA participant receives supportive services once (1) per month, at minimum.
COUNTY and its select HACCFs shall ensure the In-Kind Match Report is submitted to the
HACCF by the 5th of every month
K. Identify one COUNTY DBH staff person as a liaison between HACCF and
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1 COUNTY and its select HACCFs. Said individual will be responsible for:
2 1) Cash match reporting and maintaining supporting documentation;
3 2) Reviewing the referrals for pertinent documentation;
4 3) Eligibility;
5 4) Submitting the SPC referrals through Coordinated Entry Housing
6 Placement to the HACCF;
7 5) Submitting requests for SPC program training for COUNTY'S and
8 its select HACCFs' staff when necessary;
9 6) Informing the HACCF if there is a liaison staff change.
10 L. Acknowledge COUNTY and its select HACCFs may request termination of
11 housing assistance for a SPC TRA program participant who is in violation of program
12 requirements, and/or conditions of occupancy.
13 M. Ensure the SPC referral is signed by the DBH's Director or designee.
14 N. Collect universal information for purposes of reporting on the HUD Annual
15 Performance Report and the HMIS, and obtain Informed Consent/Release of Information
16 Authorization from participants and discuss anonymous reporting options with the HMIS
17 administrator if needed.
18 0. Provide access of supportive services documentation to HACCF to ensure SPC
19 program compliance and accuracy of in-kind reporting.
20 P. Acknowledge that if COUNTY and its select HACCFs are unable to submit
21 referrals or provide the required in-kind match in supportive services, the HACCF will have the
22 right to reduce or eliminate the allocated SPC TRA Certificates for the COUNTY and its selected
23 HACCFs.
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Q. Acknowledge HACCF reserves the right to disperse the SPC Certificate to
other providers who have a signed MOU, ability to utilize the Certificates, and provide the in-
kind match.
3. TERM
This Agreement shall become effective as of July 1, 2015 and shall terminate on the
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30th day of June 2018. Effective June 30,2018, this Agreement, subject to available funding each
year, shall be extended for two (2) additional twelve (12) month periods upon the same terms and
conditions herein set forth, unless written notice of non-renewal is given by HACCF or COUNTY or
COUNTY'S DBH Director or designee not later than sixty (60) days prior to the close of the current
Agreement term.
4. TERMINATION
A. Non-Allocation of Funds-The terms of this Agreement, and the services to
be provided thereunder are contingent on the approval of funds by the appropriating government
agency. Should sufficient funds not be allocated, the services provided may be modified, or this
Agreement may be terminated by thirty (30) days prior notice given one party to the other.
B. Breach of Contract-The COUNTY may immediately suspend or terminate
this Agreement in whole or in part, where in the determination of the COUNTY there is:
A failure to comply with any term of this Agreement;
A substantially incorrect or incomplete report submitted to the COUNTY.
C. Without Cause -Under circumstances other than those set forth above, this
Agreement may be terminated by HACC~ or COUNTY or COUNTY's DBH Director, or
designee, upon the giving of thirty (30) days advance written notice of an intention to
terminate.
5. COMPENSATION
The supportive services conducted pursuant to the terms and conditions of this
Agreement shall be performed without the payment of any monetary consideration by HACCF
or COUNTY, one to the other. However, clients successfully participating in the SPC TRA
program will be receiving rental assistance on a case by case basis through Certificates provided
by the HACCF.
6. INDEPENDENT CONTRACTOR
In performance of the work, duties, and obligations assumed by HACCF under
this Agreement, it is mutually understood and agreed that HACCF, including any and all of
HACCF's officers, agents, and employees will at all times be acting and performing as an
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1 independent contractor, and shall act in an independent capacity and not as an officer, agent,
2 servant, employee, joint venturer, partner, or associate of the COUNTY. Furthermore,
3 COUNTY shall have no right to control or supervise or direct the manner of method by which
4 HACCF shall perform its work and function. However, COUNTY shall retain the right to
5 administer this Agreement so as to verify that HACCF is performing its obligations in accordance
6 with the terms and conditions thereof. HACCF and COUNTY shall comply with all applicable
7 provisions of law and the rules and regulations, if any, of governmental authorities having
8 jurisdiction over matters which are directly or indirectly the subject of this Agreement.
9 Because of its status as an independent contractor, HACCF shall have absolutely no
10 right to employment rights and benefits available to COUNTY employees. HACCF shall be
11 solely liable and responsible for providing to, or on behalf of, its employees all legally-required
12 employee benefits. In addition, HACCF shall be solely responsible and save COUNTY harmless
13 from all matters relating to payment ofHACCF's employees, including compliance with Social
14 Security, withholding and all other regulations governing such matters. It is acknowledged that
15 during the term of this Agreement, HACCF may be providing services to others unrelated to the
16 COUNTY into this Agreement.
17 7. MODIFICATION
18 Any matters of this Agreement may be modified from time to time by the written
19 consent of all the parties without, in any way, affecting the remainder.
20 Notwithstanding the above, changes in addresses to which notices are to be sent may
21 be made by written approval of COUNTY's DBH Director or designee and HACCF.
22 8. NON-ASSIGNMENT
23 Neither party shall assign, transfer or subcontract this Agreement nor their rights or
24 duties under this Agreement without the prior written consent of the other party.
9. HOLD-HARMLESS 25
26 A. HACCF agrees to indemnify, save, hold harmless, and at COUNTY's request,
27 defend COUNTY, its officers, agents, employees from any and all costs and expenses, including
28 attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to
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1 COUNTY in connection with the performance, or failure to perform, by HACCF, its officers,
2 agents or employees under this Agreement, and from any and all costs and expenses, including
3 attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to any
4 person, finn or corporation who may be injured or damaged by the performance, or failure to
5 perform, ofHACCF, its officers, agents or employees under this Agreement. In addition,
6 HACCF agrees to indemnify COUNTY for Federal, State of California and/or local audit
7 exceptions resulting from noncompliance herein on the part ofHACCF.
8 B. COUNTY and HACCF shall give timely notice to the other of any claim,
9 demand, lien or suit coming to its knowledge which in any way might affect the other party and
10 each party shall have the right to participate in the defense of the same to the extent of its
11 interest. COUNTY and HACCF recognize that the significant mutual benefits of this
12 Agreement depend upon close cooperation and good faith handling of matters subject to such
13 indemnification provisions.
14 10. INSURANCE
15 Without limiting COUNTY's right to obtain indemnification from HACCF or any
16 third parties, HACCF, at its sole expense, shall maintain in full force and effect the following
17 insurance policies or a program of self-insurance, including but not limited to, an insurance
18 pooling arrangement of Joint Powers Agreement (JPA) throughout the term of this
19 Agreement:
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Commercial General Liability
Commercial General Liability Insurance with limits of not less than One
Million Dollars ($1,000,000) per occurrence and an annual aggregate of
Two Million Dollars ($2,000,000). This policy shall be issued on a per
occurrence basis. COUNTY may require specific coverage including
completed operations, product liability, contractual liability, Explosion,
Collapse, and Underground (XCU), fire legal liability or any other liability
insurance deemed necessary because of the nature of this Agreement.
Automobile Liability
Comprehensive Automobile Liability Insurance with limits for bodily
injury ofnot less than Two Hundred Fifty Thousand Dollars ($250,000) per
person, Five Hundred Thousand Dollars ($500,000) per accident and for
property damages of not less than Fifty Thousand Dollars ($50,000), or
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such coverage with a combined single limit of Five Hundred Thousand
Dollars ($500,000). Coverage should include owned and non-owned
vehicles used in connection with this Agreement.
Professional Liability
IfHACCF employs licensed professional staff( e.g. Ph.D., R.N., L.C.S.W.,
M.F.T.) in providing services, Professional Liability Insurance with Limits
of not less than One Million Dollars ($1 ,000,000) per occurrence, Three
Million Dollars ($3,000,000) annual aggregate.
Worker's Compensation
A policy of Worker's Compensation Insurance as may be required by the
California Labor Code.
HACCF shall obtain endorsements to the Commercial General Liability insurance
naming the County of Fresno, its officers, agents, and employees, individually and collectively, as
additional insured, but only insofar as the operations under this Agreement are concerned. Such
coverage for additional insured shall apply as primary insurance and any other insurance, or self-
insurance, maintained by COUNTY, its officers, agents and employees shall be excess only and
not contributing with insurance provided under HACCF's policies herein. This insurance shall not
be cancelled or changed without a minimum of thirty (30) days advance written notice given to
COUNTY.
Within thirty (30) days from the date HACCF signs this Agreement, HACCF shall
Provide certificates of insurance and endorsements as stated above for all of the foregoing
policies, as required herein, to the County of Fresno, Department of Behavioral Health, 3313 N.
Millbrook, Fresno CA., 93703, Attention: Contracts Division, stating that such insurance coverage's
have been obtained and are in full force; that the County of Fresno, its officers, agents and
employees will not be responsible for any premiums on the policies; that such Commercial
General Liability insurance names the County of Fresno, its officers, agents and employees,
individually and collectively, as additional insured, but only insofar as the operations under this
Agreement are concerned; that such coverage for additional insured shall apply as primary
insurance and any other insurance, or self-insurance, maintained by COUNTY, its officers, agents
and employees, shall be excess only and not contributing with insurance provided under HACCF's
policies herein; and that this insurance shall not be cancelled or changed without a minimum of
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1 thirty (30) days advance, written notice given to COUNTY.
2 In the event HACCF fails to keep in effect at all times insurance coverage as herein
3 provided, COUNTY may, in addition to other remedies it may have, suspend or terminate this
4 Agreement upon the occurrence of such event.
5 All policies shall be with admitted insurers licensed to do business in the State of
6 California. Insurance purchased shall be from companies possessing a current A.M. Best, Inc.
7 rating of A FSC VII or better.
8 11. CONFIDENTIALITY
9 All services performed by HACCF under this Agreement shall be in strict
10 conformance with all applicable Federal, State of California and/or local laws and regulations
11 relating to confidentiality.
12 12. NON-DISCRIMINATION
13 During the performance of this Agreement, HACCF shall not unlawfully
14 discriminate against any employee or applicant for employment, or recipient of services, because
15 of race, religion, color, national origin, ancestry, physical disability, medical condition, marital
16 status, age or gender, pursuant to all applicable State of California and Federal statutes and
17 regulations.
18 13. CONFLICT OF INTEREST
19 No officer, agent, or employee of the COUNTY who exercises any function or
20 responsibility for planning and carrying out the services provided under this Agreement shall have
21 any direct or indirect personal financial interest in this Agreement. The HACCF shall comply
22 with all Federal, State of California, and local conflict of interest laws, statutes, and regulations,
23 which shall be applicable to all parties and beneficiaries under this Agreement and any officer,
24 agent, or employee of the COUNTY.
25 14. COMPLIANCE WITH STATE REQUIREMENTS
26 HACCF recognizes that COUNTY operates its mental health system under an
27 agreement with the State of California Department of Health Care Services, and that under said
28 agreement the State of California imposes certain requirements on the COUNTY and its
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1 subcontractors. HACCF shall adhere to all State of California requirements, including those
2 identified in Exhibit D, attached hereto and by this reference incorporated herein.
3 15. AUDITS AND INSPECTIONS
4 The HACCF shall at any time during business hours, and as often as the COUNTY may
5 deem necessary, make available to the COUNTY for examination all of its records and data with
6 respect to the matters covered by this Agreement. The HACCF shall, upon request by the COUNTY,
7 permit the COUNTY to audit and inspect all such records and data necessary to ensure HACCF's
8 compliance with the terms of this Agreement.
9 16. NOTICES
10 The persons having authority to give and receive notices under this Agreement and their
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COUNTY OF FRESNO
Director, Fresno County
Department of Behavioral Health
4441. E. Kings Canyon Road
Fresno, CA. 93702
HACCF
Executive Director
Fresno Housing Authority
1331 Fulton Mall
Fresno, CA. 93727-2014
Any and all notices between the COUNTY and the HACCF under this Agreement or by
law, shall be in writing and be deemed duly served when personally delivered to one of the parties, or
in lieu of such personal service, when deposited in the United States Mail, postage prepaid, addressed
to such party.
17. SEVERABILITY
The provisions of this Agreement are severable. The invalidity or unenforceability of
any one provision of the Agreement shall not affect the other provisions.
18. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
A. The parties to this Agreement shall be in strict conformance with all applicable
Federal and State of California laws and regulations, including but not limited to Sections 5328,
10850, and 14100.2 et seq. ofthe Welfare and Institutions Code, Sections 2.1 and 431.300 et seq. of
Title 42, Code of Federal Regulations (CFR), Section 56 et seq. of the California Civil Code and the
Health Insurance Portability and Accountability Act (HIP AA), including but not limited to Section
1320 D et seq. of Title 42, United States Code (USC) and its implementing regulations, including, but
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1 not limited to Title 45, CFR, Sections 142, 160, 162, and 164, The Health Information Technology for
2 Economic and Clinical Health Act (HITECH) regarding the confidentiality and security of patient
3 information, and the Genetic Information Nondiscrimination Act (GINA) of 2008 regarding the
4 confidentiality of genetic information.
5 Except as otherwise provided in this Agreement, HACCF, as a Business
6 Associate of COUNTY, may use or disclose Protected Health Information (PHI) to perform functions,
7 activities or services for or on behalf of COUNTY, as specified in this Agreement, provided that such
8 use or disclosure shall not violate the Health Insurance Portability and Accountability Act (HIPAA),
9 USC 1320d et seq. The uses and disclosures of PHI may not be more expansive than those applicable
10 to COUNTY, as the "Covered Entity" under the HIPAA Privacy Rule (45 CFR 164.500 et seq.),
11 except as authorized for management, administrative or legal responsibilities of the Business
12 Associate.
13 B. HACCF, including its subcontractors and employees, shall protect, from
14 unauthorized access, use, or disclosure of names and other identifying information, including genetic
15 information, concerning persons receiving services pursuant to this Agreement, except where
16 permitted in order to carry out data aggregation purposes for health care operations [45 CFR Sections
17 164.504 (e)(2)(i), 164.504 (3)(2)(ii)(A), and 164.504 (e)(4)(i)] This pertains to any and all persons
18 receiving services pursuant to a COUNTY funded program. This requirement applies to electronic
19 PHI. HACCF shall not use such identifying information or genetic information for any purpose other
20 than carrying out HACCF's obligations under this Agreement.
21 c. HACCF, including its subcontractors and employees, shall not disclose any such
22 identifying information or genetic information to any person or entity, except as otherwise specifically
23 permitted by this Agreement, authorized by Subpart E of 45 CFR Part 164 or other law, required by
24 the Secretary, or authorized by the client/patient in writing. In using or disclosing PHI that is
25 permitted by this Agreement or authorized by law, HACCF shall make reasonable efforts to limit
26 PHI to the minimum necessary to accomplish intended purpose of use, disclosure or request.
27 D. For purposes of the above sections, identifying information shall include, but not
28 be limited to name, identifying number, symbol, or other identifying particular assigned to the
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individual, such as finger or voice print, or photograph.
E. For purposes of the above sections, genetic information shall include genetic
tests of family members of an individual or individual, manifestation of disease or disorder of family
members of an individual, or any request for or receipt of, genetic services by individual or family
members. Family member means a dependent or any person who is first, second, third, or fourth
degree relative.
F. HACCF shall provide access, at the request of COUNTY, and in the time and
manner designated by COUNTY, to PHI in a designated record set (as defined in 45 CFR Section
164.501 ), to an individual or to COUNTY in order to meet the requirements of 45 CFR Section
164.524 regarding access by individuals to their PHI. With respect to individual requests, access shall
be provided within thirty (30) days from request. Access may be extended ifHACCF cannot provide
access and provides individual with the reasons for the delay and the date when access may be
granted. PHI shall be provided in the form and format requested by the individual or COUNTY.
HACCF shall make any amendment(s) to PHI in a designated record set at the
request of COUNTY or individual, and in the time and manner designated by COUNTY in accordance
with 45 CFR Section 164.526.
HACCF shall provide to COUNTY or to an individual, in a time and manner
designated by COUNTY, information collected in accordance with 45 CFR Section 164.528, to permit
COUNTY to respond to a request by the individual for an accounting of disclosures of PHI in
accordance with 45 CFR Section 164.528.
G. HACCF shall report to COUNTY, in writing, any knowledge or reasonable
22 belief that there has been unauthorized access, viewing, use, disclosure, security incident, or breach of
23 unsecured PHI not permitted by this Agreement of which it becomes aware, immediately and without
24 reasonable delay and in no case later than two (2) business days of discovery. Immediate notification
25 shall be made to COUNTY's Information Security Officer and Privacy Officer and COUNTY's DPH
26 HIPAA Representative, within two (2) business days of discovery. The notification shall include, to
27 the extent possible, the identification of each individual whose unsecured PHI has been, or is
28 reasonably believed to have been, accessed, acquired, used, disclosed, or breached. HACCF shall take
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1 prompt corrective action to cure any deficiencies and any action pertaining to such unauthorized
2 disclosure required by applicable Federal and State Laws and regulations. HACCF shall investigate
3 such breach and is responsible for all notifications required by law and regulation or deemed necessary
4 by COUNTY and shall provide a written report of the investigation and reporting required to
5 COUNTY's Information Security Officer and Privacy Officer and COUNTY's DPH HIPAA
6 Representative. This written investigation and description of any reporting necessary shall be
7 postmarked within the thirty (30) working days of the discovery of the breach to the addresses below:
County of Fresno
Dept. of Public Health
HIP AA Representative
(559) 600-6439
P.O. Box 11867
Fresno, CA 93775
County of Fresno
Dept. of Public Health
Privacy Officer
(559) 600-6405
P.O. Box 11867
Fresno, CA 93775
County of Fresno
Information Technology Services
Information Security Officer
(559) 600-5800
2048 N. Fine Street
Fresno, CA 93727
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12 H. HACCF shall make its internal practices, books, and records relating to the use
13 and disclosure of PHI received from COUNTY, or created or received by the HACCF on behalf of
14 COUNTY, in compliance with HIPAA's Privacy Rule, including, but not limited to the requirements
15 set forth in Title 45, CFR, Sections 160 and 164. HACCF shall make its internal practices, books, and
16 records relating to the use and disclosure of PHI received from COUNTY, or created or received by
17 the HACCF on behalf of COUNTY, available to the United States Department ofHealth and Human
18 Services (Secretary) upon demand.
19 HACCF shall cooperate with the compliance and investigation reviews
20 conducted by the Secretary. PHI access to the Secretary must be provided during the HACCF's
21 normal business hours, however, upon exigent circumstances access at any time must be granted.
22 Upon the Secretary's compliance or investigation review, if PHI is unavailable to HACCF and in
23 possession of a subcontractor, it must certify efforts to obtain the information to the Secretary.
24 I. Safeguards
25 HACCF shall implement administrative, physical, and technical safeguards as
26 required by the HIPAA Security Rule, Subpart C of 45 CFR 164, that reasonably and appropriately
27 protect the confidentiality, integrity, and availability of PHI, including electronic PHI, that it creates,
28 receives, maintains or transmits on behalf of COUNTY and to prevent unauthorized access, viewing,
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1 use, disclosure, or breach of PHI other than as provided for by this Agreement. HACCF shall conduct
2 an accurate and thorough assessment of the potential risks and vulnerabilities to the confidential,
3 integrity and availability of electronic PHI. HACCF shall develop and maintain a written information
4 privacy and security program that includes administrative, technical and physical safeguards
5 appropriate to the size and complexity ofHACCF's operations and the nature and scope of its
6 activities. Upon COUNTY's request, HACCF shall provide COUNTY with information concerning
7 such safeguards.
8 HACCF shall implement strong access controls and other security safeguards
9 and precautions in order to restrict logical and physical access to confidential, personal (e.g., PHI) or
10 sensitive data to authorized users only. Said safeguards and precautions shall include the following
11 administrative and technical password controls for all systems used to process or store confidential,
12 personal, or sensitive data:
1. Passwords must not be: 13
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a. Shared or written down where they are accessible or recognizable
by anyone else; such as taped to computer screens, stored under keyboards, or visible in a work area;
b. A dictionary word; or
c. Stored in clear text
2. Passwords must be:
a. Eight (8) characters or more in length;
b. Changed every ninety (90) days;
21 c. Changed immediately if revealed or compromised; and
22 d. Composed of characters from at least three (3) of the following
23 four (4) groups from the standard keyboard:
24 1) Upper case letters (A-Z);
25 2) Lowercase letters ( a-z);
26 3) Arabic numerals (0 through 9); and
27
28
4) Non-alphanumeric characters (punctuation symbols).
HACCF shall implement the following security controls on each workstation or
-15 -COUNTY OF FRESNO
Fresno. CA
1 portable computing device (e.g., laptop computer) containing confidential,
2 personal, or sensitive data:
Network-based firewall and/or personal firewall;
Continuously updated anti-virus software; and
3
4
5
I.
2.
3. Patch management process including installation of all operating
6 system/software vendor security patches.
7 HACCF shall utilize a commercial encryption solution that has received FIPS
8 140-2 validation to encrypt all confidential, personal, or sensitive data stored on portable electronic
9 media (including, but not limited to, compact disks and thumb drives) and on portable computing
10 devices (including, but not limited to, laptop and notebook computers).
11 HACCF shall not transmit confidential, personal, or sensitive data via e-mail or
12 other internet transport protocol unless the data is encrypted by a solution that has been validated by
13 the National Institute of Standards and Technology (NIST) as conforming to the Advanced Encryption
14 Standard (AES) Algorithm. HACCF must apply appropriate sanctions against its employees who fail to
15 comply with these safeguards. HACCF must adopt procedures for terminating access to PHI when employment
16 of employee ends.
17 J. Mitigation of Harmful Effects
18 HACCF shall mitigate, to the extent practicable, any harmful effect that is
19 suspected or known to HACCF of an unauthorized access, viewing, use, disclosure, or breach ofPHI
20 by HACCF or its subcontractors in violation of the requirements of these provisions. HACCF must
21 document suspected or known harmful effects and the outcome.
22 K. HACCF's Subcontractors
23 HACCF shall ensure that any of its HACCFs, including subcontractors, if
24 applicable, to whom HACCF provides PHI received from or created or received by HACCF on behalf
25 of COUNTY, agree to the same restrictions, safeguards, and conditions that apply to HACCF with
26 respect to such PHI and to incorporate, when applicable, the relevant provisions ofthese provisions
27 into each subcontract or sub-award to such agents or subcontractors.
28 L. Employee Training and Discipline
-16 -COUNTY OF FRESNO
Fresno. CA
1 HACCF shall train and use reasonable measures to ensure compliance with the
2 requirements ofthese provisions by employees who assist in the performance of functions or activities
3 on behalf of COUNTY under this Agreement and use or disclose PHI and discipline such employees
4 who intentionally violate any provisions of these provisions, including termination of employment.
5 M. Termination for Cause
6 Upon COUNTY's knowledge of a material breach of these provisions by
7 HACCF, COUNTY shall either:
8 I. Provide an opportunity for HACCF to cure the breach or end the
9 violation and terminate this Agreement if HACCF does not cure the breach or end the violation within
10 the time specified by COUNTY; or
11 2. Immediately terminate this Agreement if HACCF has breached a material
12 term of these provisions and cure is not possible.
13 3. If neither cure nor termination is feasible, the COUNTY's Privacy
14 Officer shall report the violation to the Secretary of the U.S. Department of Health and Human
15 Services.
16 N. Judicial or Administrative Proceedings
17 COUNTY may terminate this Agreement in accordance with the terms and
18 conditions ofthis Agreement as written hereinabove, if: (1) HACCF is found guilty in a criminal
19 proceeding for a violation ofthe HIPAA Privacy or Security Laws or the HITECH Act; or (2) a
20 finding or stipulation that the HACCF has violated a privacy or security standard or requirement of the
21 HITECH Act, HIPAA or other security or privacy laws in an administrative or civil proceeding in
22 which the HACCF is a party.
23 0. Effect of Termination
24 Upon termination or expiration of this Agreement for any reason, HACCF shall
25 return or destroy all PHI received from COUNTY (or created or received by HACCF on behalf of
26 COUNTY) that HACCF still maintains in any form, and shall retain no copies of such PHI. !fretum
27 or destruction of PHI is not feasible, it shall continue to extend the protections of these provisions to
28 such information, and limit further use of such PHI to those purposes that make the return or
-17 -COUNTY OF FRESNO
Fresno. CA
1 destruction of such PHI infeasible. This provision shall apply to PHI that is in the possession of
2 subcontractors or agents, if applicable, of HACCF. If HACCF destroys the PHI data, a certification of
3 date and time of destruction shall be provided to the COUNTY by HACCF.
4 P. Disclaimer
5 COUNTY makes no warranty or representation that compliance by HACCF with
6 these provisions, the HITECH Act, HIP AA or the HIP AA regulations will be adequate or satisfactory
7 for HACCF's own purposes or that any information in HACCF's possession or control, or transmitted
8 or received by HACCF, is or will be secure from unauthorized access, viewing, use, disclosure, or
9 breach. HACCF is solely responsible for all decisions made by HACCF regarding the safeguarding of
10 PHI.
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
Q. Amendment
The parties acknowledge that Federal and State laws relating to electronic data
security and privacy are rapidly evolving and that amendment of these provisions may be required to
provide for procedures to ensure compliance with such developments. The parties specifically agree
to take such action as is necessary to amend this agreement in order to implement the standards and
requirements of HIP AA, the HIP AA regulations, the HITECH Act and other applicable laws relating
to the security or privacy of PHI. COUNTY may terminate this Agreement upon thirty (30) days
written notice in the event that HACCF does not enter into an amendment providing assurances
regarding the safeguarding of PHI that COUNTY in its sole discretion deems sufficient to satisfy the
standards and requirements of HIP AA, the HIP AA regulations and the HITECH Act.
R. No Third-Party Beneficiaries
Nothing express or implied in the terms and conditions of these provisions is
intended to confer, nor shall anything herein confer, upon any person other than COUNTY or HACCF
and their respective successors or assignees, any rights, remedies, obligations or liabilities whatsoever.
S. Interpretation
The terms and conditions in these provisions shall be interpreted as broadly as
necessary to implement and comply with HIP AA, the HIP AA regulations and applicable State laws.
The parties agree that any ambiguity in the terms and conditions of these provisions shall be resolved
-18 -COUNTY OF FRESNO
Fresno. CA
1 in favor of a meaning that complies and is consistent with HIP AA and the HIP AA regulations.
2 T. Regulatory References
3 A reference in the terms and conditions of these provisions to a section in the
4 HIP AA regulations means the section as in effect or as amended.
5 U. Survival
6 The respective rights and obligations ofHACCF as stated in this Section shall
7 survive the termination or expiration of this Agreement.
8 V. No Waiver of Obligations
9 No change, waiver or discharge of any liability or obligation hereunder on any
10 one or more occasions shall be deemed a waiver of performance of any continuing or other obligation,
11 or shall prohibit enforcement of any obligation on any other occasion.
12 19. DATA SECURITY
13 For the purpose of preventing the potential loss, misappropriation or inadvertent access,
14 viewing, use or disclosure of COUNTY data including sensitive or personal client information; abuse
15 of COUNTY resources; and/or disruption to COUNTY operations, individuals and/or agencies that
16 enter into a contractual relationship with the COUNTY for the purpose of providing services under
17 this Agreement must employ adequate data security measures to protect the confidential information
18 provided to CONTRACTOR by the COUNTY, including but not limited to the following:
19 A. HACCP-Owned Mobile, Wireless, or Handheld Devices
20 HACCP may not connect to COUNTY networks via personally-owned mobile,
21 wireless or handheld devices, unless the following conditions are met:
22 1) HACCP has received authorization by COUNTY for
23 telecommuting purposes;
2)
3)
4)
Current virus protection software is in place;
Mobile device has the remote wipe feature enabled; and
A secure connection is used.
24
25
26
27
28
B. HACCP -Owned Computers or Computer Peripherals
-19 -COUNTY OF FRESNO
Fresno. CA
1 HACCP may not bring HACCP -owned computers or computer peripherals into
2 the COUNTY for use without prior authorization from the COUNTY's Chief Information Officer,
3 and/or designee(s), including but not limited to mobile storage devices. If data is approved to be
4 transferred, data must be stored on a secure server approved by the COUNTY and transferred by
5 means of a Virtual Private Network (VPN) connection, or another type of secure connection. Said
6 data must be encrypted.
7 c. COUNTY -Owned Computer Equipment
8 HACCP may not use COUNTY computers or computer peripherals on non-
9 COUNTY premises without prior authorization from the COUNTY's Chieflnformation Officer,
10 and/or designee(s).
11 D. HACCP may not store COUNTY's private, confidential or sensitive data on any
12 hard-disk drive, portable storage device, or remote storage installation unless encrypted.
13 E. HACCP shall be responsible to employ strict controls to ensure the integrity and
14 security of COUNTY's confidential information and to prevent unauthorized access, viewing, use or
15 disclosure of data maintained in computer files, program documentation, data processing systems,
16 data files and data processing equipment which stores or processes COUNTY data internally and
17 externally.
18 F. Confidential client information transmitted to one party by the other by means of
19 electronic transmissions must be encrypted according to Advanced Encryption Standards (AES) of
20 128 BIT or higher. Additionally, a password or pass phrase must be utilized.
21 G. HACCP is responsible to immediately notify COUNTY of any violations,
22 breaches or potential breaches of security related to COUNTY's confidential information, data
23 maintained in computer files, program documentation, data processing systems, data files and data
24 processing equipment which stores or processes COUNTY data internally or externally.
25 H. COUNTY shall provide oversight to HACCP's response to all incidents arising from a
26 possible breach of security related to COUNTY's confidential client information provided to HACCP.
27 HACCP will be responsible to issue any notification to affected individuals as required by law or as
28 deemed necessary by COUNTY in its sole discretion. HACCP will be responsible for all costs
-20 -COUNTY OF FRESNO
Fresno. CA
1 incurred as a result of providing the required notification.
2 19. PROHIBITION ON PUBLICITY
3 None of the funds, materials, property or services provided directly or indirectly under
4 this Agreement shall be used for HACCF's advertising, fundraising, or publicity (i.e., purchasing of
5 tickets/tables, silent auction donations, etc.) for the purpose of self-promotion. Notwithstanding the
6 above, publicity of the services described in Section 1 of this Agreement shall be allowed as necessary
7 to raise public awareness about the availability of such specific services when approved in advance by
8 COUNTY's DBH Director or his/her designee and at a cost to be provided in Exhibit C for such items
9 as written/printed materials, the use of media (i.e., radio, television, newspapers) and any other related
10 expense(s).
11 20. GOVERNING LAW
12 The parties agree that for the purpose of venue, performance under this Agreement is in
13 Fresno County, California.
14 The rights and obligations of the parties and all interpretation and performance of this
15 Agreement shall be governed in all respects by the laws of the State of California.
16 21. ENTIRE AGREEMENT
17 This Agreement, including all Exhibits, constitutes the entire agreement between
18 HACCF and COUNTY with respect to the subject matter hereof and supersedes all previous agreement
19 negotiations, proposals, commitments, writings, advertisements, publications, and understandings of
20 any nature whatsoever unless expressly included in this Agreement.
21 ///
22 Ill
23 Ill
24 Ill
25 Ill
26 Ill
27 Ill
28 ///
-21 -COUNTY OF FRESNO
Fresno. CA
1 IN WITNESS WHEREOF, the parties hereto have executed this Amendment I to MOU as of
2 the day and year first hereinabove written.
3 ATTEST:
4 OWNER:
5 FRESNO HOUSING AUTHORITY
6
11 PrintName: Preston Prince ------------------
12
13 Title: CEO/Executive Director ------------------------
14 Executive Director
15
16
17
18
19
20
COUNTY OF FRESNO
Chairman, Board of Supervisor
Date:
BERNICE E. SEIDEL, Clerk
Board of Supervisors
21 Date: -=I-~ d. dJJ/6
2 2 Mailing Address:
2 3 Fresno Housing Authority
2 4 1331 Fulton Street
25 Fresno, CA. 93727-2014
2 6 Phone No.: (559) 443-8400
2 7 Contact: Doreen Eley
2 8 Shelter Plus Care Program Manager
PLEASE SEE ADDITIONAL
SIGNATURE PAGE(S) ATTACHED
-22 -COUNTY OF FRESNO
Fresno, CA
RESOLUTION N0._2425
BEFORE THE BOARD OF COMMISSIONERS OF THE
HOUSING AUTHORITY OF THE COUNTY OF FRESNO
RESOLUTION AU1HORIZING APPROVAL TO RENEW THE SHELTER PLUS CARE
PARTNERSHIP AGREEMENT WITII COUNTY OF FRESNO DEPARTMENT OF
BEHAVIORAL HEALTH
WHEREAS, the Fresno Housing Authority has received U.S. Department of Housing and
Urban Development funding to administer the legacy Shelter Plus Care (SPC) program; and,
WHEREAS,' said prowam is a tenant based rental assistance. program intended to assist
homeless households with disabling conditions; and,
WHEREAS, Fresno Housing intends to renew partnership with County of Fresno
Department of Behavioral Health to administer supportive services to clients in said program;
and,
WHEREAS, this joint effort is a best practice model to aid in housing retention and
required for all CoC permanent supportive housing programs as the minimum 25% in-kind
match contribution;
NOW THEREFORE, BE IT RESOLVED that the Board of Commissioners of the Housing
Authority of the County of Fresno, hereby authorize the Executive Director or his designee to
proceed with negotiation and execute all ancillary documents in connection therewith to renew
the Shelter Plus Care partnership agreement with County of Fresno Department of Behavioral
Health.
PASSED AND ADOPTED TillS 28th DAY OF April, 2015. I, the undersigned, herby
certify that the foregoing Resolution was duly adopted by the governing body with the
following vote, to-wit:
A YES: Commissioners Sablan, Petty, Anthony, and Miller.
NOES: None.
ABSENT: Commissioners Nelson and Eager.
ABSTAIN: None.
RESOLUTION N0._3518_
BEFORE THE BOARD OF COMMISSIONERS OF THE
HOUSING AUTHORITY OF THE OTY OF FRESNO
RESOLUTION AUTIIORIZING APPROVAL TO RENEW THE SHELTER PLUS CARE
PARTNERSHIP AGREEMENT WITH COUNTY OF FRESNO DEPARTMENT OF
BEHAVIORAL HEALTH
WHEREAS, the Fresno Housing Authority has received U.S. Department of Housing and
Urban Development funding to administer the. legacy Shelter Plus Care (SPC) program; and,
WHEREAS, said program is a tenant based rental assistance program intended to ·assist
homeless households with disabling conditions; and,
WHEREAS, Fresno Housing intends to renew partnership with County of Fresno
Department of Behavioral Health to administer supportive services to clients in said program;
and,
WHEREAS, this joint effort is a best practice model to aid in housing retention and
. required for all CoC permanent supportive housing programs as the minimum 25% in-kind
match contribution;
NOW THEREFORE, BE IT RESOLVED that the Board of Commissioners of the Housing
Authority of the City of Fresno, hereby authorize the Executive Director or his designee to
proceed with negotiation and execute all ancillary documents in connection therewith to renew
the Shelter Plus Care partnership agreement with County of Fresno Department of Behavioral
Health.
PASSED AND ADOPTED TillS 28th DAY OF April, 2015. I, the undersigned, herby
certify ·that the foregoing Resolution was duly adopted by the governing body with the
following vote, to-wit:
A YES: Commissioners Scharton, Scott, Jones, Lowe, and Johnson.
NOES: None.
ABSENT: Commissioners Bedrosian and Aguilar.
ABSTAIN: None.
1 APPROVED AS TO LEGAL FORM:
2 DANIEL C. CEDERBORG, COUNTY COUNSEL
3
4
5 By __ ~--~~~--------------
6
7
8
9 APPROVED AS TO ACCOUNTING FORM:
10 VICKI CROW, C.P.A., AUDITOR-CONTROLLER/
11 TREASURER-TAX COLLECTOR
12
13
14 Byeu r:~
15
16
17
18 REVIEWED AND RECOMMENDED FOR
19 APPROVAL:
20
21
22 By--.:~:...__---~-----
23 Dawan Utecht, Director
24 Department of Behavioral Health
25
26 Fund/Subclass:
27 Organization:
28 Account:
0001/10000
56302999
7295/0
$0
-23 -COUNTY OF FRESNO
Fresno. CA
Exhibit A FRESNO~~Jt~~J
sgeM~XHOUSING
AUTHORITY~~~~~ www.fresnohousing.org
1331 Fulton Mall, Fresno, California 93721 (559) 443-8400 TTY (Boo) 735-2929
SHELTER PLUS CARE, TENANT-BASED RENTAL ASSISTANCE (SPC-TRA)
PRE-APPLICATION AND REFERRAL FORM
PLEASE NOTE: The referred applicant must be disabled and currently homeless i.e .. 1)
sleeping in places not meant for hnman habitation, 2) living in emergency shelter, 3) living in
transitional housing for lw111eless bnt came from the streets/shelter. or 4) persons coming from a
short term stay in an institution (up to a m<Lximum of 90 consecutive days) who previously
resided on the streets or in ,emergency shelters to qualify for the SPC-TRA Program. In addition.
the patiicipant must continue receiving supportive services to remain eligible for housing
assistance through the SPC-TRA Program.
This section to be completed by the Referring Agency
Name of Applicant (please print)-----------------------
SSN ----------------Phone Number _________ _
Current address or place of residence----------------------
City State ______ Zip Code ________ _
Date of Birth ---------------Age _____________ _
Gender D Male D Female D Transgender
Veteran
Veteran Status D N/ A D
Referring Agency Contact Information
This section to be completed by the Referring Agency
Date of Referral ______ _ Referring Agency
Print Name Title
Fax Number E-mail Address ----------
Services
This section to be completed by the Refl:;rring Agency
What type of services does the applicant receive from your agency?
(e.g., mental health services, employment, living skills, transportation, education, etc .. )
Will these services continue after housing is received? DYes 0No
)'
Exhibit A
What type of services does the applicant receive from other supportive services agencies?
(e.g., mental health services, employment, living skills, transportation, education, etc ... )
Type of Service Name of Service Provider
If the answer to the above is NO, STOP-the applicant is not eligible to participate in the SPC-
TRA Program.
SPC Eligibility (Please provide the homeless certification signed by the Executive Director or designee on
agency letterhead) (See Exhibit A-3)
This section to be completed by the RefetTing Agency
The applicant is (check all that applies):
D Sleeping in places not meant for human habitation
D Sleeping in emergency shelters
D Living in transitional housing for homeless persons but came from the streets/shelter
D SafeHaven
D Persons from a short-term stay (up to 30 consecutive days) in an institution who
previously resided on the streets or in emergency shelters
D None of the above (NOTE: If none of the above, then this person is NOT eligible for the
SPC TRA Program)
How long has the applicant been homeless?-----------------
Chronically Homeless (Please provide the homeless and disability certification signed by the Executive
Director or designee on agency letterhead) (See Exhibit A-4)
This section to be completed by the Referring Agency
Choose one:
a. D This person has been homeless continuously for at least one year (i.e., streets, shelter)
b. D This person has had at least 4 episodes ofhomelessness for the past 3 years (i.e., streets,
shelter)
NOTE: If you checked box (a) or (b) complete the Chronically Homeless Certification
form
c. D This person has NOT been homeless continuously for 1 year or at least 4 times in the
past 3 years
Prior Living Situation (check all that apply)
This section to be completed by the Referring Agency
a. 0 Non-Housing (street, park, bus station, etc.)
b. 0 Emergency Shelter
c. 0 Transitional housing for homeless persons
d. D Psychiatric Facility
e. 0 Substance Abuse treatment facility
£ 0 Hospital
Exhibit A
g. 0 Jail/prison
h. 0 Domestic Violence Situation
1. D Living with relatives/friends
J. D Rental Housing
k. D Other, specify:
Disability Eligibility (Please attach the disability certification signed by a State Licensed
qualified source and the Executive Director or designee on agency letter head) (See exhibit A-2)
The applicant is diagnosed with one or more of the following (Refer to the definition from
Exhibit A-2. Check all that apply):
0 Chronic alcohol and /or substance abuse
0 Severe mental illness
0 AIDS or related diseases
0 Physical or visual disability
D Developmental Disability
D None of the above (NOTE: If none of the above, then this person is NOT eligible_for the
SPC TRA Program)
Special Needs (check all that apply)
This section to be completed by the Referring Agency
a. D Mental illness e. D Physical Disability
b. D Alcohol Abuse
c. D Drug Abuse
d. D HIV I AIDS and Related Diseases
f. D Domestic Violence
g. D Other, specify:
h. D Developmental Disability
Exhibit A
Transitional Plan
This section to be completed by the Referring Agency
What are the applicant's plans to ensure success in independent housing (e.g., employment, life
skill training, education, volunteering, treatment, etc)?
~ . ~_:_-~· ~--~J ·----=---·=r=-~t~~~~U'~kD __ ~~~
Employment
Education
Living Skills
Medical
Transportation
Housing
Other
Other
I hereby certify that all the information stated herein is true and accurate.
Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties.
(18 U.S.C. 1001, 1010, 1012; 31U.S.C. 3729, 3802)
Executive Director or Designee (Signature) Date
Executive Director or Designee (Print or type name)
Exhibit A
Housing Authority Use Only-SPC Referral Selection Approval Sheet
The applicant meets the criteria for SPC TRA definition of homeless?
The applicant has a qualifying disability?
DYes
DYes
DNo
DNo
Supporting Documents for homeless status and disability have been provided (check all that
applies):
1. Homeless:
D Homeless certification form with supporting documentation
D Chronically Homeless certification form with supporting documentation
2. Disability:
OMental Illness
OAicohol Abuse
ODrugAbuse
0HIV /Related Disability
Housing Authority Use Only -SPC Staff Comments
Housing Authority Use Only-Disposition
0Developmental Disability
0Physical Disability
0Visual Disability
0Domestic Violence
Based on the information included in the SPC-TRA Referral Form, the applicant's request for a
SPC-TRA has been:
D Approved
Denied due to:
D Lack of documentation ( D Disability D Homelessness D Other)
D Applicant does not meet the criteria for homelessness
D Applicant does not have a documented disability
D Other: -------------
Signature of Housing Authority Representative Date
Title
Exhibit B
(REFERRING AGENCY MAY USE TillS FORMAT ON AGENCY LETTERHEAD)
Shelter Plus Care Program
DISABILITY CERTIFICATION
In order to be eligible for participation in the SPC program, an applicant must have at least one of the
targeted disabilities established by HUD for this program, and must meet HUD' s defmition of disability.
Please verify that the person named below meets these requirements by completing Section I and II.
Name of Applicant to SPC Program: _________________ _
Section 1: Targeted Disabilities
The applicant has one or more of the following targeted SPC disabilities (please check all that apply)
D SMI-Serious Mental Illness
D CSA-Chronic Substance Abuse with alcohol, drugs, or both
D SMI&CSA
D AIDS or Related Diseases
D Other Disability (24 CFR 582.5)
(1) A developmentally disabled person is one with a severe chronic disability
that:
(a) Is attributable to a mental and/or physical impairment;
(b) As manifested before the age of22;
(c) Is likely to continue indefinitely;
(d) Results in substantial functional limitations in three or more of the
following areas or major life activity: capacity for independent
living, self-care, receptive and expressive language; learning,
mobility, self-direction, and economic self-sufficiency, AND;
(e) Requires special interdisciplinary or generic care treatment, or other
services which are of extended or lifelong duration and individually
planned or coordinated.
(2) A disabled person is also one who has a physical, emotional, or mental
impairment that:
(a) Is expected to be of long-continued or indefmite duration;
(b) Substantially impeded the person's ability to live independently;
(c) Is such that the person's ability to live independently could be
improved by more suitable housing conditions.
Erro
Equal Housing
Oooonunitv
Section 2: Verification ofDisabilitv
I have verified that the applicant is disabled by: (please check only one box)
0 a. The applicant is receiving Supplemental Security Income (SSI) benefits for the
targeted disability or disabilities checked above.
If you checked box (a), a copy of the applicant's SSI determination letter must be
attached.
0 b. The applicant is not receiving SSI benefits, but has one or more of the targeted
disabilities checked above AND meets the following definition of disability:
"Has a physical, mental, or emotional impairment which is expected to be of long
continued and indefinite duration: substantially impedes his or her ability to live
independently of such nature that such ability could be improved by more
suitable housing conditions."
If you checked box (b), this certification must be signed by a State License qualified
source trained to make such a determination.
This certification form must be completed at each annual re-certification.
Physician /State License qualified source Signature:-------------------
Print Name: Title: Date: ---------------------------------------
Phone Number: Fax Number: ----------------
Address: _______________________________________________________________ _
Executive Director or Designee Signature:-------------
Print Name:---------------
Date: -------------
(REFERRING AGENCY MAY USE THIS FORMAT ON AGENCY LETTERHEAD)
Shelter Plus Care Program
HOMELESSNESS CERTIFICATION
ExhibitC
The SPC Program requires written documentation of homeless status for all applicants. The person
named below has indicated that your organization has verified his or her homeless status. Please
complete this homeless certification form and provide supporting documents described on the attached
page.
Name of the Homeless Person:----------------------
Homeless Status (please check only one box)
The person named above is currently homeless because he or she is:
D Sleeping in places not meant for human habitation (such as cars, parks,
sidewalks, etc.)
D Sleeping in an emergency shelter.
D Living in Safe Haven
D Living in transitional housing for homeless person or emergency shelter and who
originally came from the streets.
D Spending a short time (90 days or less) in a hospital or other institution, but
ordinarily sleeps in emergency shelter and/or places not meant for human
habitation and was homeless upon entry to the hospital or institution.
I certify that the above information is correct to the best of my knowledge.
Signature ( CaseManager/Outreach Worker/ShelterStaft) Date
Signature (Executive Director or Designee) Date
Print Name (Executive Director or Designee) Date
Applicant Signature Date
Supporting Documentation must be attached (see the attached page for instructions)
Erro
Equal Housing
Opportunitv
Instructions for Homeless Verifications
The Homeless Certification should be completed and signed by an individual that has direct
knowledge of where the homeless person named in the certification is currently living (e.g.
outreach worker, emergency shelter staff person, transitional housing staff person, etc.).
The required forms of supporting documentation and type of staff person who may sign the
certification are summarized below.
Homeless Person's Person Who May Sign Supporting Documentation Required
Living Situation Certification
Living on streets or Staff person from social For Supportive Services Only projects that provide
other places not service organization that services --such as outreach, food, health care, and
meant for human has assisted the homeless clothing -to persons who reside on the streets, it
habitation person may not be feasible to require the homeless persons
to document that they reside on the street. It is
sufficient for the outreach staff to certify that the
persons served reside on the street. The outreach or
service worker should sign and date a general
certification verifying that services are going to
homeless persons and indicating where the persons
reside.
For all other SHP projects, the grantee or project
sponsor should obtain information to verify that a
participant is coming from the street. This may
include names of other organizations or outreach
workers who have assisted them in the recent past
who might provide documentation. If you are
unable to verify that the person is coming from the
street, have the participant prepare or you prepare a
written statement about the participant's previous
living place and have the participant sign the
statement and date it.
If an outreach worker or social service agency
referred the participant to your agency, you must
obtain written verification from the referring
organization regarding where the person has been
residing. This verification should be on agency
letterhead, signed and dated.
Erro
PnnAl I-lnuc:ino
Living in emergency
shelter
Living in transitional
housing for homeless
persons
Short-term stay (less
than 90 days) in an
institution, having
previously been on
the street or in a
shelter
ExhibitC
Staff person from The grantee or project sponsor must have written
emergency shelter in which verification from the emergency shelter staff that
the homeless person is
residing
Staff person from
transitional housing
program in which the
homeless person is
residing.
Staff person from
institution in which the
homeless person is
residing.
the participant has been residing at an emergency
shelter for homeless persons. The verification must
be on agency letterhead, signed and dated.
The grantee or project sponsor must have written
verification from the transitional housing facility
staff the participant had been residing in the
transitional housing. The verification must be on
agency letterhead, signed and dated.
The grantee or project sponsor must also have
written verification with a letter from the original
agency verifying that the participant was living on
the streets or in an emergency shelter prior to living
in the transitional housing facility (see the above
for required documentation) or was discharged
from an institution.
The grantee or project sponsor must have written
verification on agency letterhead from the
institution's staff that the participant has been
residing in the institution for 90 days or less. The
verification must be signed, dated, and on agency
letterhead. The grantee must also have written
verification that the participant was residing on the
street or in an emergency shelter prior to the short-
Erro
Equal Housing
Oooortunitv
Exhibit D
(REFERRING AGENCY MAY USE THIS FORMAT ON AGENCY LETTERHEAD)
Shelter Plus Care Program
CHRONICALLY HOMELESSNESS CERTIFICATION
The SPC Program requires written documentation of chronically homeless SPC program applicants.
Please complete this certification form and provide supporting documents described on the attached page.
Please note: In order to qualifY as chronically homeless, an applicant must have a disabling condition.
The Housing Authority of the City of Fresno (Housing Authority) will obtain a separate verification of
disability.
Name of Chronically Homeless Person:. _________________ _
Chronically Homeless Status (please check only one box)
An individual or family who:
D Has been continuously homeless for more than one year (either living in the streets,
other places not meant for human habitation, or in an emergency shelter or some
combination of these places)
D Has had at least four episodes ofhomelessness in the past three years (an episode is
defmed as living in the streets, other places not meant for human habitation, or in an
emergency shelter).
I certifY that the above information is correct to the best of my knowledge.
Case Manager, Outreach Worker, Shelter Staff Signature:-----------------
Print Name: Date: ________ _
Executive Director or Designee Signature:----------------------
Print Name: Date:--------------
Applicant Signature: Date:---------
Supporting Documentation must be attached (see attached page for instructions)
Erro
Equal Housing
Oooortunitv
Instructions for Chronically Homeless Certification
The Chronically Homeless Certification should be completed and signed by an individual that
has had contact with and has some knowledge of the chronically homeless person named on the
certification, such as an outreach worker, drop-in center worker or shelter staff person.
The person completing the certification must attach a brief statement attesting that:
• The homeless person named in the certification is currently either living in the streets,
place not meant for human habitation, or an emergency shelter.
• To the best of this staff person's knowledge, the homeless person has either been
homeless for 12 consecutive months or 4 times in the past 3 years.
The statement should include any information about the homeless person's activities that help
document his or her history ofhomelessness (e.g. showering at drop-in center for past two
years).
If the staff person providing the certification has known the homeless person for less than 12
months, he or she should include a statement from the homeless person attesting to his or her
past history ofhomelessness. This certification should include information (e.g. dates and
locations) about previous emergency shelter and/or street stays. This statement should be signed
by the homeless individual.
What is a disabling condition?
A disabling condition is defmed as "a diagnosable substance use disorder, serious mental illness,
developmental disability, or chronic physical illness or disability, including the co-occurrence of
two or more of these conditions. A disabling condition limits an individual's ability to work or
perform one or more activities of daily living."
What is an episode of homelessness?
An episode ofhomelessness is a separate, distinct, and sustained stay on the streets and/or in an
emergency homeless shelter.
Who is Chronically Homeless?
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 shall be considered chronically homeless if such person met all the
requirements described above prior to entering that facility.
Erro
Equal Housing
Oooortunitv
Exhibit E
www.fresnohousing.org
1331 Fulton Mall, Fresno, California 93721 (559) 443-8400 TTY (Soo) 735-2929
Shelter Plus Care Program (SPC)
Participant-Service Provider Agreement
The purpose of this agreement is to document the commitment of the supportive services agency for
providing services to the SPC Program participant, and to clearly outline the roles and responsibilities of
the participant and service provider in regards to service provision for SPC program compliance.
Name of the Service Provider: ---------------------------------------------
Name of the Case Manager:-----------------------
Phone Number of the Case Manager: _________ Fax Number: _______ _
Name of the Participant:-------------------------
By signing the document, the Service Provider agrees to:
);> Act as the primary service provider for the above-named participant.
);> Assign a case manager to work with the participant and to be the main contact person for the Housing
Authority of the City ofFresno (Housing Authority).
);> Assist the participant to develop an Individual Service Plan designed to help maintain housing stability, and
meet the participant's self-directed goals.
);> Assist the participant to access services he/she has identified in the Individual Service Plan.
);> Provide documentation of the services provided to the participant. Communicate promptly with the Housing
Authority, regarding any concerns about the participant's housing stability.
);> Provide the participant and Housing Authority with a 180-day notice of intent to terminate this agreement.
);> Provide the Housing Authority with the required cash match in supportive services for the SPC participant
By signing this document, the Participant agrees to:
);> Maintain regular contact with the identified Case Manager.
);> Meet with the Case Manager at least once per month (or less ifmutually agreed with case manager).
);> Work with the case manager to achieve the goals in the Individual Service Plan.
);> Communicate promptly with Housing Authority regarding any concerns with regard to the supportive services
received.
);> Provide the Service Provider and Housing Authority with 60-day notice of intent to terminate this agreement.
);> Authorize the staff of the Housing Authority and the Supportive Service agency to share information relating
to SPC rental assistance and supportive services required for SPC program participation.
);> Inform Service Provider if receiving supportive services from other service agencies.
Authorized Service Provider Representative
Participant's Signature
Housing Authority Staff
Date
Date
Date
Erro
--·
Equal Housing
Opportunity
Exhibit F FRESNO~~~~~~!
sge~I~XHOUSING
AUTHORITY~~s~t~~~ www.fresnohousing.org
:1.33:1. Fulton Mall, Fresno, California 9372:1. (559) 443-8400 TTY (Boo) 735-2929
SHELTER PLUS CARE PROGRAM (SPC)
AUTHORIZATION FOR RELEASE OF
CONFIDENTIAL INFORMATION
Participant Name----------
SPC Certificate Number--------
Service Provider Name---------
Service Provider Staff ________ _
Date ______________ ___
I authorize the staff of Housing Authorities City and County of Fresno and personnel of the following
agencies below to share information relating to my SPC housing and supportive services.
D Angels of Grace
D Resources for Independence Central Valley
D Central Valley Regional Center
D Department of Behavioral Health
D County of Fresno Employment & Temporary
Assistance
D Fresno Interdenominational Refugee Ministries
D West Care/The Living Room
D Fresno County Economic Opportunities
Commission
D CMC Specialty Health Center
D Samaritan Woman
D Poverello House
D Alternative Vocational Services Employment
D Fresno Center for New Americans
D Spirit of Women
D Fresno Unified School District-Project Access
D Catholic Charities
D Opportunity Assistance & Socially Integrated
Services
D Department of Public Health
D Department of Veterans Affairs
D Fresno Unified School District-Lowell
Elementary School
D Kings View
D Marjaree Mason Center
D Department of Children and Family Services
D Fresno Rescue Mission
D CMC Community Connections
D Turning Point
D Other ________ _
I understand that all information is confidential, and that no information will be released to any other person
outside of these agencies without my consent.
I understand that I can revoke this authorization at any time by providing the Housing Authorities City and
County of Fresno with written notification.
I certify that I have read (or had read to me) and understand the contents of this form.
I understand and agree that a photocopy of this form and my signature shall be considered as valid as the
original. This document is valid for two years.
Participant Signature:----------------------
Dare: __________________ _
If you are a person with disabilities and require reasonable accommodation, you must submit your request in writing or call Andrea
Garcia at 559 457-4264. The Housing Authority will make all reasonable efforts in assisting persons with disabilities. Examples of
reasonable accommodations include: Home Visits, TDD or TDV access and/or use of an interpreter.
TTY (800) 735-292 G:t
EQUAL HOUSING
OPPORTUNJJY
www.hafresno.org
Exhibit G
Program Entry Date: __/ __} __ _ HMISID#:
First Name: ________ _ Middle Name: Last Name: Suffix (Jr,Sr,etc.): __ _
Alias: _________ Social Security Number: ____ -Birth Date:__/__/ __ _
( )Full SSN ( )Partial SSN ( )Don't Know ( )Refused ( )Full DOB ( )Partial DOB ( )Don't Know ( )Refused
Gender: ( )Male ( )Female ( )Transgender M to F ( )Transgender F to M ( )Other ( )Don't Know ( )Refused
Ethnicity: ( )Hispanic/Latina ( )Non-Hispanic/Latina ( )Don't Know ( )Refused
Race: ( )White ( )American Indian or Alaska Native ( )Asian ( )Black or African-American ( )Native Hawaiian or Other Pacific Islander
( )Don't Know ()Refused
Clientrelationshiptoheadofhousehold(~applkable): _____________________________ _
Does the client have a physical, mental, emotional or developmental disability, HIV/AIDS, or a diagnosable substance abuse problem that is
expected to be of long duration and substantially limits their ability to live on their own?
()Yes ()No ()Don't Know ()Refused
Special Considerations: If Yes, currently receiving services or treatment for Expected to be of long-continued and indefinite
this condition? duration and substantially impairs ability to live
independently?
Physical Disability ()Yes ()No ( )Don't Know ()Refused ()Yes ()No ( )Don't Know ( )Refused N/A
Developmental Disability ()Yes ()No ( )Don't Know ()Refused ()Yes ()No ( )Don't Know ( )Refused N/A
Chronic Health Condition ()Yes ()No ( )Don't Know ()Refused ()Yes ()No ()Don't Know ()Refused N/A
HIV/AIDS ()Yes ()No ( )Don't Know ()Refused ()Yes ()No ( )Don't Know ( )Refused N/A
Mental Health Problems ()Yes ()No ( )Don't Know ()Refused ()Yes ()No ( )Don't Know ( )Refused ()Yes ()No ( )Don't Know ( )Refused
Substance Abuse ( )Alcohol ( )Drugs ( )Both ()Yes ()No ( )Don't Know ( )Refused {)Yes ()No ( )Don't Know ( )Refused
Problem ( )No ( )Don't Know ( )Refused
Domestic violence victim/survivor: ( )Yes ( )No ( )Don't Know ( )Refused;
If "Yes," when experience occurred: ()Within past 3 months () 3-6 months ago ( )6-12 months ago ()More than a year ago ()Don't Know ()Refused
ExhibitG
Residence Prior to Program Entry: (where did client sleep last night)
( }Emergency Shelter (including a youth shelter or hotel, motel, or campground ( )Transitional housing for homeless persons (including homeless youth)
paid for with emergency shelter voucher)
( )Permanent housing for formerly homeless person(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 center ( )Rental by client, no ongoing housing subsidy
( )Owned by client, no ongoing housing subsidy ( )Staying/living in family member's room, apt.,house
( )Staying/living in a friend's room, apt., or house
( )Foster care home or foster care group home
()Rental by client, with VASH housing subsidy
( )Safe haven
( )Other ( )Don't Know
How long did client stay at that place?
( )Hotel or motel paid for w/o emergency shelter voucher
( )Place not meant for habitation(e.g. a vehicle, an abandoned building,
bus/train/subway station/airport or anywhere outside)
()Rental by client, with other(non-vASH} housing subsidy
( )Owned by client, with ongoing housing subsidy
()Refused
( )One week or less ( )More than one week, less than on month ( )One to three months ( )More than three months, less than one year
( )One year or longer ( )Don't know ( )Refused
What is the zip code of last permanent addreSS(house or apartment that client lived in for 3months or longer): _______ (enter ooooo if client refused/doesn't
know)
( )Full or partial zip code reported ( )Don't know ( )Refused
Housing status: ( )Literally homeless ( }Imminently losing their housing ( )Unstably housed and at risk of losing their housing ( )Stable housed
( )Don't Know ( )Refused
Is client homeless: ( )Yes ( )No Is client chronically homeless? ( )Yes ( )No
Income Received in Past 30 Days? ( )Yes ( )No ( )Don't know ( )Refused If Yes, check off all that apply and list amounts:
( )Earned Income $ ( )Unemployment Insurance$ __ _ ( )Supp. Sec. Income (SSI) $ __ _
( )Veteran's disability payment$ __ _ ( )Private disability insurance$ __ _ ( )Worker's compensation $ __ _
( )TANF or local program $ __ _ ( )General Assistance (GA) or local program$ __ _ ()Veteran's Pension $ __ _
( )Retirement income from Social Security$ __ _ ( )Pension from former job $ __ _ ( )Child support $ __ _
( )Alimony or other spousal support$ __ _ ( )Other source $ __ _
Non-cash benefits received from any source in the past 30 days? ( )Yes ( )No ( )Don't know ( )Refused
( )SNAP (Food Stamps)
()WIC
()MEDICAID health insurance program
( )TANF child care services
( )MEDICARE health insurance program
( )TANF transportation services
Exhibit G
If "YES" check off all that apply:
()State Children's Health Insurance Program
( )Other TANF funded services
()VA medical services ()Temporary rental assistance ( )Section 8, public housing or other ongoing rental assistance
()Other source ___________ _
Have you ever served on active duty in the Armed Forces of the United States?
( )Yes ( ) No ( )Don't Know ( )Refused
Service Transactions should be entered into HM/5 when services are rendered.
Fresno Madera Continuum of Care
Client Informed Consent & Release of Information Authorization
Homeless Management Information System (HMIS)
Exhibit H
___________ is a Partner Agency in the Homeless Management Information System
(HMIS). HMIS is a shared homeless and housing database system administered by The Housing Authority
City of Fresno. HMIS can improve the services and programs for homeless and low income households by
allowing authorized staff at Partner Agencies to share client information and to follow trends and service
patterns over time. HMIS operates over the internet and uses many security protections to ensure
confidentiality.
Participation in the HMIS program is important to our community's ability to provide you with the best
services and housing possible. As you receive services, information will be collected about you, the services
provided to you, and the outcomes these services help you to achieve.
• Your name and other identifying information will not be shared with any agency not participating in
the system (unless required to do so by law.)
• Your name, gender, race, social security number and date of birth may be shared with Partner
Agencies for Identification purposes even if you elect not to share other relevant information.
• Sensitive information such as diagnosis or treatment or mental health disorders, drug or alcohol
disorders, HIV I AIDS, or domestic violence concerns, will not be shared between Partner Agencies
without specific written consent.
• A list of Partner Agencies is available upon request.
• Authorizing your information to be entered into the HMIS is voluntary.
• Refusing to do so will not limit your access to shelter or services.
Please initial one of the following levels of consent:
__ (1) I give authorizations for my basic and relevant information to be entered into the HMIS and shared
between Partner Agencies. I understand that I have the right to receive a copy of all information shared
between the Partner Agencies.
__ (2) I give authorization for my basic and relevant information to be entered into the HMIS, but not
shared between Partner Agencies.
I understand that I may cancel this authorization at any time by written request, but the cancellation will not
be retroactive. 1 understand that I have the right to view my HMIS record and will have a report prepared
within 72 hours of my written request. I understand that if I refuse consent to share this information I cannot
be denied services. I understand that this release is valid for from the date of my signature.
Print Name ofHead ofHousehold Date Print Name of Adult Date
Signature of Head ofHousehold Date Signature of Adult Date
Print Name of Child Date Signature of Adult for Child Date
Fresno Madera Continuum of Care
HMIS partner Agencies
Effective 10/2011
Angels of Grace
AspiraNet
Central California Legal Services
Community Action Agency Partnership of Madera-Shunammite Place
County of Fresno-Adult Protective Services
_ Fresno County Economic Opportunities Commission-Sanctuary Youth Services
Housing Authority City and County of Fresno
Marjaree Mason Center
Mental Health Systems
Poverello-Naomi's House
Resources for Independence central Valley
Spirit of Women
Turning Point
Valley Teen Ranch
WestCare California
Exhibit H
FRESNOYJ~!t~~! Exhibit I
S~eM~XHOUSING
AUTHORITY~~s~~~~ www.fresnohousing.org
~33~ Fulton Mall, Fresno, California 9372~ (559) 443-8400 TTY (Boo) 735-2929
SHELTER PLUS CARE APPLICATION FOR INITIAL OCCUPANCY
Head of Household Name: _________________ Address:-----------------
Phone No.: ________ Message Phone No. ________ Message Contact Name:-----------
Entity ID: ______ Anniversary Date: ______ ,Increment No. ________ .Packet Due Date:. ______ _
. A,:~):IOliSEHOLQ(:Cii\nPO~IjiQ~ >/ .· :;:~;J;;, ' ·.::·1 ·~ -·~.::· '}E'-<)?/·1' <-,e, ,;> -~;·\~~'<"~-:;.·_ .':?•,, .)~{'::· ·:":I;: /::_:')L;:·.~;·: )_i!(. -~;=· '); .:.
RELATIONSHIP RACE DISABLED SEX BIRTH SOCIAL SECURITY NO.
ADULTS (LEGAL NAMES) YIN M/F DATE
1 HEAD
2 SPOUSE/
CO-HEAD
3
CHILDREN (LEGAL NAMES)
4
5
6
7
8
ARE ANY ADULT FAMILY MEMBERS CURRENTLY ENROLLED AS A FULL TIME "or" PART-TIME STUDENT? 0 YESO NO
If "yes" read and complete the following:
Family Member's Name: D Full time D Part time
NAME OF SCHOOL: ADDRESS:
PHONE NUMBER:
If you are under the age of 24, not married, do not have dependents and are not a U.S. Veteran, you must pick up a "Student Verification
Information Sheef' from our office or download one from our website at www.hafresno.org, and attach to this packet. If there is more than one
adult attending school FT or PT, provide this information on a separate sheet of paper.
Are any family members a US Veteran? DYes D No If "yes," who?
LIST BELOW ALL PERSONS WHO MOVED OUT IN THE PAST 12 MONTHS (INCLUDE DEATHS, MARRIAGES, PERMANENT PLACEMENT IN NURSING HOME, ETC.
FULL NAME RELATIONSHIP DATE OF MOVE OUT REASON
DO YOU ANTICIPATE ADDING OR REMOVING ANY MEMBERS OF YOUR HOUSEHOLD? 0 YESO NO
IF "YES" EXPLAIN:
B. REASONABLE ACCOMONDATIONS List any family member (s) who require{s) reasonable accommodation and the type of
accommodation being requested:
Household Member Type of Accommodation Being Requested
Household Member Type of Accommodation Being Requested
C. DISCLOSURE OF CONFLICT OF INTEREST
Are you or any family member{s) related to any Housing Authority employee or Housing Authority Commissioner? o Yes o No
If Yes, please provide the following:
First and Last Name of Employee I Commissioner Relationship
ELIGIBILITY 1 of14 RX PACKET (Rev. 03120/I3)
~ ~ ~ ~ 1\.) g, ...... ~ ~ ~ ~ ""! ~ ~ ~ ;::; ~ ~ PENSION $ $ $ HOURLY RATE: $ HRS WORKED IAn:::<:VIV• HOURLY RATE: $ _ HRS WORKED WEEKLY: Are any earnin!:ls SELF-t:MC~ nVMI=I\l Assets/Cash Do you ora member of Checking$ Acct No. .,--Bank Checking$ AcctNo. ~--Bank Does any member of !=' ::1: 0 c en m ::1: 0 .-c z 0 0 s:: m I "TI !!. E" ~ .... 0 ~ "0 0 ~ :;· n 0 3 CD iii' cc a c :I Q. Ill 0' ... S' 3 :;· ~ 0 ? 0 ~ '< 0 c ... E 0 i ., ::::;; '< 0 c :r ~ .c c CD Ill cr. 0 :I !II ~ ~ ~ ::::;.· ........
Exhibit I
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E. OTHER INCOME
1. Do you receive Gifts, Contributions, Help from Family/Friends/Other?_ Yes No
If "yes" what amount $ and how often? __ Weekly __ Monthly __ Other
What for?
EUGIBILITY 3of14 RX PACKET (Rev. 03120113)
Exhibit I
2. Does any family member work for someone who pays them cash? Yes No
If "yes" what amount $ and how often? __ Weekly _ Monthly Other
What for? --
3. Have you or any family member received a lump sum payment in the past year? _Yes No
If "yes" Explain: -
F. TANF RECIPIENTS ONLY
4. Do you have any overpayment in TANF benefits? Yes No
If "yes" please attach your overpayment letter to this packet and state the amount of the overpayment here: $
5. Are you or anyone in the household being sanctioned in your TANF benefits? Yes No -"Sanctioned" means you are receiving less than the full TANF grant normally awarded
If "yes" who?
If "yes" why? o Fraud by a family member in connection with the welfare program o Noncompliance with a work activities requirement.
o Failure to participate in an economic self-sufficiency program. o Other:
o Penalty for non-cooperation with DA's Office
6. Are you timed out with your TANF benefits? _Yes _No
7. If there are any family members not on the cash grant, list their names and state the reason why they are not on the grant.
o MFB Baby (Child born after 9/1/97) Who?
o Minor not attending school or unsatisfactory grades:
G. EXPENSES
1. Have there been any changes during the past 12 months in your household expenses involving MEDICAL EXPENSES,
including expenses related to the care of a disabled member, Medicare, medical insurance, medical assistance from the Welfare
Department and outstanding medical bills to doctors, pharmacies or other medical facilities?_ Yes _ No
If "yes" explain:
2. Is the head of household or spouse paying out of pocket child care expenses for children under the age of 13 that enables
him/her to work, attend school or participate in a job-training program?_ Yes _No
If "yes" provide the name, address and phone number of the child care provider and the number of hours child care is provided
on a separate sheet of paper and include it with this packet.
H. FAMILIES WITH DISABILITIES (Head of Spouse is permanently disabled).
Do you pay for a care attendant or pay for any equipment for a disabled member of the family necessary to permit that person or
someone else in the family to work? -Yes -No
If "yes" describe the expenses:
I. ELDERLY I DISABLED FAMILIES ONLY (Head or Spouse must be at least 62 years of age or permanently disabled).
What is your Medicare premium? $
If you have any other kind of medical insurance, give policy number and agent's name:
Policy Number: Agent:
Medical insurance premium that you pay monthly is $
If you have any outstanding medical bills on which you are paying that are not covered by medical insurance, describe them
here:
If you expect to have any medical expenses during the next 12 months that are not covered by medical insurance, list annual
amount:$ __
J. PRIVACY ACT STATEMENT
The information on these forms is being collected by the Department of HUD to determine an applicant's/participant's eligibility, the
recommended unit size, and the amount of contribution by the tenant(s). It will be used to provide the basis for managing the programs
covered by this form, for protecting the government's financial interest, and for verifying the accuracy of the information furnished. It may be
ELIGIBIUTY 4 of 14 RX PACKET (Rev. 03120113)
Exhibit I
released to appropriate federal, state and local agencies when relevant to civil, criminal or regulatory investigators or prosecutors. Failure to
provide information may result in a delay or rejection of your eligibility approval or termination of a participant's assistance. The department
is authorized to ask for this information by the U.S. Housing Act of 1937 as amended, 42 U.S.C., 1437 et seq, the Housing and Community
Development Amendments of 1981, P.L. 97.35.85 Stat, 348.408.
APPLICANT I TENANT CERTIFICATION
1. GIVING TRUE AND COMPLETE INFORMATION: 1/We certify that all information provided on household composition, income, family
assets and items for allowances and deductions are true and complete to the best of my/our knowledge.
2. CHANGES IN INCOME OR HOUSEHOLD COMPOSITION: 1/We know that 1/We are required to report immediately any changes in
income, or when a person moves out of the unit. 1/We understand that any changes to my family composition (except for the birth,
adoption, or court-awarded custody of a child) must be approved by the Housing Authority BEFORE additional family members may move
in. 1/We understand that all changes in the income of any family member of the household must be reported within 30 calendar days of
the change. Any changes in the household members must be reported to the Housing Authority within 10 business days from the date of
the change.
3. NO DUPLICATE RESIDENCE OR ASSISTANCE: 1/We certify that 1/We have disclosed where 1/we received any previous Federal
Housing Assistance and whether or not money is owed. 1/We certify that for this previous assistance 1/we did not commit any fraud,
knowingly misrepresent any information, or vacate the unit in violation of the lease.
4. COOPERATION: 1/We know 1/We are required to cooperate in supplying all information needed to determine my/our eligibility, level of
benefits, or verify my/our true circumstances. Cooperation includes attending prescheduled meetings. Supplying false, incomplete, or
inaccurate information is grounds for termination of housing assistance.
5. CRIMINAL AND ADMINISTRATIVE ACTIONS FOR FALSE INFORMATION: 1/We understand that knowingly supplying false,
incomplete, or inaccurate information is punishable under Federal or State criminal law. 1/We understand that knowingly supplying false,
incomplete, or inaccurate information is grounds for termination of housing assistance.
6. RELEASE OF INFORMATION: I the undersigned, acknowledge that I have received a copy of these SPC Contract of Participation.
Furthermore, I have read and understood these obligations and failure to comply with any of them may result in the cancellation of my
assistance.
7. SPC CONTRACT OF PARTICIPATION): To receive housing assistance, each recipient must be lawfully within the United States. "I
certify, under penalty of perjury, that to the best of my knowledge I am lawfully within the United States. The responsible adult must sign
for all family members under 18 years of age.
8. STATEMENT OF FAMILY OBLIGATIONS: I, the undersigned, acknowledge that I have received a copy of these Family Obligations.
Furthermore, I have read and understood these obligations and failure to comply with any of them may result in the cancellation of my
assistance.
9. GROUNDS FOR DENIAL OR TERMINATION BY THE HOUSING AUTHORITY: The Housing Authority may, at any time, deny program
assistance for any applicant, or terminate program assistance for a participant. I have read the attached information and understand my
assistance can be cancelled for the reasons listed.
10. CONSENT FOR RELEASE OF INFORMATION: I hereby authorize you to release to the Housing Authority of the City and County of
Fresno, California, information regarding verification of family composition and family income requested by them. In the event I should
vacate the premises prior to full settlement of incurred obligations, my forwarding address is also to be released to the Housing Authority.
11. MOVING PROCEDURES: 1/We have been informed that 1/We must contact the Housing Authority before 1/We move from my/our current
unit. If 1/We fail to provide a 30-day written notice, 1/we are aware that my/our assistance may be cancelled.
APPLICANT CERTIFICATION
UNDER PENAL TV OF PERJURY, 1/we certify that the information given in Sections A through I is accurate and complete to the best of my/our
knowledge and belief. 1/We have read and understand the above Applicant/Tenant Certification. 1/We understand any attempt to obtain Shelter
Plus Care housing by providing false information, impersonation, failure to disclose, or other fraud (and any act of assistance to such attempt) is
a crime punishable under federal law. Warning: 18 U.S.C. 1000 provides, among other things, that whoever knowingly and willfully makes or
uses a document or writing containing any false, fictitious, or fraudulent statement or entry, in any matter within the jurisdiction of any department
or agency of the United States, shall be fined not more than $10,000, imprisoned for not more than five years, or both.
Signature of Head of Household Date Signature of Spouse or Co-Head Date
Signature of Other Adult 18 or over Date Signature of Other Adult 18 or over Date
Signature of Other Adult 18 or over Date Signature of Other Adult 18 or over Date
EUGJBILITY 5of14 RX PACKET (Rev. 03120113)
Authorization for the Release of Information/
Privacy Act Notice
·To the U.S. Department of Housing and Urban Development (HUD)
And the Housing/Agency/Authority (HA)
U.S. Department of Housing
and Urban Development
Exhibit I
Office of Public and Indian Housing
PHA requesting release of information: IRA requesting release of information:
Housing Authorities of the City and County of Fresno
POBox 11985
Fresno CA 93776-1985
Authority: Section 904 of the Stewart B. McKinney Homeless
Assistance Amendments Act of 1988, as amended by Section 903
of the Housing and Community Development Act of 1992 and
Section 3003 of the Omnibus Budget Reconciliation Act of 1993.
This law is found at 42 U.S.C. 3544.
This law requires that you sign a consent form authorizing: (1)
HUD and the Housing Agency/Authority (HA) to request
verification of salary and wages from current or previous
employers: (2) HUD and the HA to information from the state
agency responsible for keeping that information: (3) HUD to
request certain tax return information from the U.S. Social Security
Administration and the U.S. Internal Revenue Service. The law
also requires independent verification of income information.
Therefore, HUD or the HA may request information from financial
institutions to verify your eligibility and level of benefits.
Purpose: In signing this consent form, you are authorizing HUD
and the above-named HA to request income information from the
sources listed on the form. HUD and the HA need this information
to verify your household's income in order to ensure that you are
eligible for assisted housing benefits and that these benefits are set
at the correct level. HUD and the HA may participate in computer
matching programs with these sources in order to verify your
eligibility and level of benefits.
Uses of Information to be Obtained: HUD is required to protect
the income information it obtains in accordance with the Privacy
Act of 1974, U.S.C. 552a. HUD may disclose information (other
than tax return information) for certain routine uses, such as to
other government agencies for law enforcement purposes and to
HA's for the purpose of determining housing assistance. The HA
is also required to protect the income information it obtains in
accordance with any applicable State privacy law. HUD and HA
employees may be subject to penalties for unauthorized disclosures
or improper uses of the income information that is obtained based
on the consent form. Private owners may not request or receive
information authorized by this form.
Who Must Sign the Consent Form: Each member of your
household who is 18 years of age or older must sign the consent
form. Additional signatures must be obtained from new adult
members joining the household or whenever members of the
household become 18 years of age.
Original is retained by the requesting organization.
ELIGIBILITY
Persons who apply for or receive assistance under the following
programs are required to sign this consent form
PHA-owned rental public housing
Turnkey III Home Ownership Opportunities
Mutual Help Home Ownership Opportunity
Section 23 and 19(c) leased housing
Section 23 Housing Assistance Payments
HA-owned rental Indian housing
Section 8 Rental Certificate
Section 8 Rental Voucher
Section 8 Moderate Rehabilitation
Failure to Sign Consent Form: Your failure to sign the consent
form may result in the denial of eligibility or termination of
assisted housing benefits, or both. Denial of eligibility or
termination of benefits is subject to the HA's grievance procedures
and Section 8 informal hearing procedures.
Sources of Information to be Obtained
State Wage Information Collection Agencies: (This consent is
limited to wages and unemployment compensation I have received
during period(s) within the last 5 years when I have received
assisted housing benefits.)
U.S. Social Security Administration (HUD only)(This consent is
limited to the wage and self employment information and
payments of retirement income as referenced Section
6103(1)(7)(A) of the Internal Revenue Service Code.)
U.S. Internal Revenue Service (HUD only) (This consent is limited
to earned income [i.e., interest and dividends].)
Information may also be obtained directly from: (a) current and
former employers concerning salary and wages and (b) financial
institutions concerning unearned income (i.e., interest and
dividends). I understand that income information obtained from
these sources will be used to verify information that I provide in
determining eligibility for assisted housing programs and the level
of benefits. Therefore, this consent form only authorizes release
directly from employers and financial institutions of information
regarding any period(s) within the last 5 years when I have
received assisted housing benefits.
Ref. Handbooks 7420.7, 7420.8, & 7420.1 Form HUD 9886 (7/94)
6of14 RX PACKET (Rev. 03/l0/13)
Exhibit I
Consent: I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form for
the purpose of verifying my eligibility and level of benefits under HUD's assisted housing programs. I understand that HAs that
receive income information under this consent form cannot use it to deny, reduce or terminate assistance without first
independently verifying what the amount was, whether I actually had access to the funds and when the funds were received. In
addition, I must be given an opportunity to contest those determinations.
This consent form expires 15 months after signed.
Signatures:
Signature of Head of Household Date
Social Security Number (if any) of Head of Household Signature of Other Family Member over age 18 Date
Signature of Spouse or Co-Head Date Signature of Other Family Member over age 18 Date
Signature of Other Family Member over 18 Date Signature of Other Family Member over age 18 Date
Privacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this information by the
U.S. Housing Act of 1937 (42 U.S.C. 1437 et. Seq.) Title VI of the Civil Rights Act of 1964 (42 U.S.S. 2000d), and by the Fair Housing Act
(42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants and participants to submit
the Social Security Number of each household member who is six years or older. Purpose: Your income and other information are being
collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your family will pay toward rent and utilities.
Other Uses: HUD uses your family income and other information to assist in managing and monitoring HUD-assisted housing programs to
protect the Government's financial interest, local agencies, when relevant, and to civil, criminal, or regulatory investigators and prosecutors.
However the information will not be otherwise disclosed or released outside ofHUD, except as permitted or required by law. Penalty: You
must provide all of the information requested by the HA, including all Social Security Numbers you, and all other household members six years
and older, have and use. Giving the Social Security Numbers will affect your eligibility. Failure to provide any of the requested information
may result in a delay or rejection of your eligibility approval.
Penalties for Misusing this Consent:
HUD, the HA and any owner (or any employee of HUD, the HA or the owner) may be subject to penalties for unauthorized disclosures or improper uses of
information collected based on the consent form.
Use of the information collected based on the form HUD 9886 is restricted to the purposes cited on the form HUD 9886. Any person who knowingly or willfully
requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more
than $5,000.
Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, against
the officer or employee of HUD, the HA or the owner responsible for the unauthorized disclosure or improper use.
Original is retained by the requesting organization. ref. Handbooks 7420.7, 7420.8, &7465.1 Form HUD 9886 (7/94)
ELIGIBILITY 7of14 RX PACKET (Rev. 03/20/13)
Exhibit I
FRESNO~§!t~~~! __________________ ....;:H=ous~ing:.:,:;Pro~grams=
S~e~/~XHOUSING
AUTHORITY~~~te~W GENERAL RELEASE OF INFORMATION
INSTRUCTIONS: Please copy this form and complete for each household member
age 18 and older.
CONSENT: I authorize and direct any Federal, State, or local agency, organization, business, or individual to release to the
Housing Authority of the City and County of Fresno (HACCF}, any infonnation or materials needed to complete and verify
my application for participation, and/or maintain my continued assistance under the Shelter Plus Care Program. I
understand and agree that this Authorization or the information obtained will be used by HACCF in administering and
enforcing Program rules and policies.
INFORMATION COVERED: Verifications and inquiries that may be requested includes, but are not limited to:
Criminal Reports Credit Reports Eviction Reports Sex Offender Reports
Family Composition Assets School Records Child Care Allowance
AGENCIES: Agencies that may be asked to release infonnation includes, but are not limited to:
Other Public Agencies Child Care Providers Financial Institutions Alimony Providers
Law Enforcement Agency Internal Revenue Services Child Protective Services Welfare Agencies
Utility Companies Educational Institutions Post Offices Courts
Last Name: First Name:
Middle Name: Suffix: Social Security#: - -
Drivers/Identification License#: Phone Number#:
Date of Birth (DOB): I I Sex: FemaleD MaleD
I DO hereby authorize the release of information to the Housing Authority of the City and County of Fresno. I agree
that a photocopy of this Authorization may be used for the purposes stated above. The original of this Authorization
is on file with the PHA and will stay in effect for twelve months from the date signed.
Signature: Date:
IMPORTANT: The following law authorizes the collection of this information by HUD or the PHA: The U.S. Housing Act
of 1937 (42 U.S.C., 1437 et seq.) Any information obtained from criminal history is confidential and shall not be disclosed
other than for the purpose of admission and/or continued assistance. The criminal history information in the possession of
the authority and all copies made from it shall be destroyed after the authority's fmal decision whether to act on the
housing.
ELIGIBILITY Bof14 RX PACKET (Rev. 03/20/13)
CRIMINAL BACKGROUND DISCLOSURE
Current Address
I
Street City State/Zip Code
Write the addresses you have lived at, in the last 5 years. If necessary, please add an attachment.
Street Citv State/Zip Code
From
From
Have you ever been known by another name? If yes, hst all other names (Also Known As-A.K.A.):
A.K.A.: A.K.A.: __________ _
Are you currently on parole or probation for any criminal offense?
Yes_No_Ifyes, please give dates and charges:-----------------
Have you ever been involved in any criminal activity?
Yes_No_Ifyes, please give dates, charges, city and state: _____________ _
Have you ever been involved in any drug related activity?
Yes_No_lfyes, please give dates, charges, city and state: ____________ _
Has any household member ever been involved with manufacturing methamphetamine?
Yes_No_Ifyes, please give dates, charges, city and state:-------------
Present
To
To
Have you ever been evicted from federally assisted housing (i.e., public housing) for drug related criminal activity?
Yes_No_lfyes, please give dates, charges, city and state:-------------
Are you currently subject to a registration requirement under a state sex offender registration program?
Yes_ No_ If yes, please explain and provide incident dates: ______________ _
Exhibit I
SIGNATURE REQUIRED: By signing below, I certify under penalty of perjury that the above information is true and correct to the best of my knowledge
Signature: _______________ _ Date: __________ _
EUGIBIUTY 9of14 RX PACKET (Rev. 03120113)
Exhibit I
FOR OFFICE USE ONLY
Section A (Completed by HACCF staff)
,--------------------------.
Head of household name: EntityiD#:
~------------------------~
HPC: Program:
I D Applicant D Resident/Participant D Household Add D Live-in Aide D Port-in
Section B: Criminal Background (Completed by Program Integrity Unit)
Final Disposition: I D Approved D Denied D Cancelled
Reviewed By: I I Signature: I Date:
EUGIBILITY 10of14 RXPACKET(Rev. 03120113)
Exhibit I
STATEMENT OF FAMILY OBLIGATIONS
Family obligations for continued assistance in a Shelter Plus Care are as follows:
1. Purpose. This section states the obligations of a participant family under the program.:.
2. Supplying required information -(1) The family must supply any information that the Public Housing
Authority(PHA) or Housing and Urban Development(HUD) determines is necessary in the administration of the
program, including any requested certification release or other documentation.
3. The family must supply any information requested by the PHA or HUD for use in a regularly scheduled
reexamination or interim reexamination of family income and composition in accordance with HUD requirements.
4. The family must disclose and verify social security numbers (as provided by part 5, subpart b, of this title) and
must sign and submit consent forms for obtaining information is accordance with part 5, sub 6 of this title.
5. Any information supplied by the family must be true and complete.
6. Housing Quality Standards (HQS) breach caused by family. The family is responsible for any HQS breach
caused by the family as described in CFR 982.404 (b).
7. Allowing PHA inspection. The family must allow the PHA to inspect the unit at reasonable times and after
reasonable notice.
8. Violation of lease. The family may not commit any serious or repeated violation of the lease.
9. Family notice of move or lease termination. The family must notify the PHA and the owner before the family
moves out of the unit, or terminates the lease on notice to the owner. See CFR 982.314 (d).
1 0. Owner eviction notice. The family must promptly give the PHA a copy of any owner eviction notice.
11. Use and occupancy of unit. -(1) The family must use the assisted unit for residence by the family. The unit must
be the family's only residence.
12. The composition of the assisted family residing in the unit must be approved by the PHA. The family must
promptly inform the PHA of the birth, adoption or court-awarded custody of a child. The family must request
PHA approval to add any other family member as an occupant of the unit. No other person [i.e., nobody but
members of the assisted family] may reside in the unit (except for a foster child or live-in aide as provided in
paragraph (h)(4) of this section).
13. The family must promptly notify the PHA if any family member no longer resides in the unit.
14. If the PHA has given approval, a foster child or a live-in-aide may reside in the unit. The PHA has the discretion
to adopt reasonable policies concerning residence by a foster child or a live-in-aide, and defining when PHA
consent may be given or denied. (Continued on Next Page)
15. Members of the household may engage in legal profit making activities in the unit, but only if such activities are
incidental to primary use of the unit for residence by members of the family.
16. The family must not sublease or leave the unit.
17. The family must not assign the lease or transfer the unit.
18. Absence from the unit. The family must supply any information or certification requested by the PHA to verify
that the family is living in the unit, or relating to family absence from the unit, including any PHA-requested
information or certification on the purposes of family absence from the unit.
19. Interest in unit. The family not own or have any interest in the unit.
20. Fraud and other program violation. The members of the family must not commit fraud, bribery or any other
corrupt or criminal act in connection with the programs.
21. Crime by household members. The members of the household may not engage in drug-related criminal activity
or violent criminal activity or other criminal activity that threatens the health, safety or right to peaceful enjoyment
of other residents and persons residing in the immediate vicinity of the premises (see CFR 982.553).
22. Alcohol abuse by household members. The members of the household must not abuse alcohol in a way that
threatens the health, safety or right to peaceful enjoyment of other residents and persons residing in the
immediate vicinity of the premises.
23. Other housing assistance. An assisted family, or members of the family, may not receive SPC tenant-based
assistance while receiving any other housing subsidy, for the same unit or for a different unit, under any
duplicative (as determined by HUD or in accordance with HUD requirements) federal, State or local housing
assistance program.
1 have read the above and understand that my assistance can be cancelled for these reasons.
Name of Head of Household (Print) Signature of Head of Household Date
ELIGIBILITY 11 of 14 RX PACKET (Rev. 03120/13)
Exhibit I
GROUNDS FOR DENIAL OR TERMINATION BY HOUSING AUTHORITY
The Housing Authority may. at any time. deny program assistance for an applicant. or terminate program assistance
for a participant. for any of the following reasons:
• If the family violates any family obligation under the SPC program;
• If any member of the family has been evicted from public housing;
• If a Housing Authority has ever terminated assistance under the certificate or voucher program for any member
of the family;
• If any member of the family commits drug-related or criminal activity;
• If any member of the family commits fraud, bribery or any other corrupt or criminal act in connection with any
federal housing program;
• If the family currently owes rent or other amounts to the Housing Authority or to another Housing Authority in
connection with Section 8 or other public housing assistance under the 1937 Act;
• If the family has not reimbursed any Housing Authority for amounts paid to an owner under a HAP contract for
rent, damages to the unit, or other amounts owed by the family under the lease;
• If the family breaches an agreement with the Housing Authority to pay amounts owed to a Housing Authority, or
other amounts to the owner paid by a Housing Authority. The Housing Authority, at its discretion, may offer a
family the opportunity to enter into an agreement to pay amounts owed to a Housing Authority or amounts paid
to an owner by a Housing Authority (the Housing Authority may prescribe the terms of the agreement);
• If the family has engaged in or threatened abusive or violent behavior toward Housing Authority personnel;
• The family's action or failure to act;
I have read the above and understand that my assistance can be cancelled for these reasons.
Name of Head of household (Print) Signature of Head of household Date
EUGIBIUTY 12 of14 RX PACKET (Rev. 03/20/13)
Exhibit I
COUNTY OF FRESNO AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION
Case Name CaseNumbe_r ____________________________ __
Worker Name---------------------------
Worker Number------------------------
Worker Telephone---------------------Dare ________________________ __
I authorize the staff of the Fresno Housing Authorities and the Fresno County Department of Social Services to discuss
eligibility factors and provide the following information relating to my CAL WORKS case(s}.
I understand that all information is confidential, and that no information will be released to any other person outside of
these two agencies without my consent.
I understand that I can revoke this authorization at any time.
I certify that I have read (or had read to me) and understand the contents of this form.
I understand and agree that a photocopy of this form and my signature shall be considered as valid as the original.
Signature:--------------------Date-------------
CSF 15 (replaces ES0075 and ES0075A)
CONSENT FOR RELEASE OF INFORMATION
EUGIBIUTY 13of14 RX PACKET (Rev. 03120113)
Exhibit I
Include the following documents in your packet-Documents cannot be older than 60 days.
::F;' : ::-,: ;; · ·, >o;'. ·· ':· • : : ',~';):i;: : ::~::;t·· ''Income Type~.:~:>· , ; '-'-." .·~ ,. ' ' ~i "i";. . Iwti~i;~~-(.:·~~~~-~~-in.~iuci~~~th'yo~;'~a~i~t:::H'.: ·::;~i':~~-;·::,;].i.·-~};~t\~;~''i~:~·l;$;~·.'.Z%.:?:·~,;~.~:::•~:·~:!I: ... ~
Adding Household If you are claiming someone who is receiving subsidy in another household, documentation
members/Multiple Subsidies must be provided verifying that they will be residing in your household.
Cash/Gifts and/or You must provide a notarized statement detailing the source and amount of cash/gifts
Contributions received monthly. For gifts, you must supply a dollar amount.
Checking and/or Statements from the last two (2} months from any bank, financial institution where any
Savings Account family member has an account.
Child Care A letter from the public agency or private entity certifying that the family pays for Child Care
Expenses. The letter must indicate the names of the children being cared for; the total
number of hours they are cared for per week/month, and the total cost per week/month
whether for work or school.
Child Support A quarterly printout from the Family Support Division, or court-awarded documents showing
the amount being paid for child support.
Disability Certification If any family member is identified as disabled, please provide the name of the certifying
professional, mailing address and phone number.
Employment or Seasonal Provide copies of your check stubs for the most current two (2} months of employment, along
Employment with your W-2, complete tax form, and/or employment printout.
Foster Care/Adoption A current WHIS report from the Department of Social Services.
Assistance Payments
General Relief Please provide a current notice of action from the Human Services System.
Job Training Letter from public agency or trade school certifying participation in a job training program.
Medical Expenses Receipts from your physician, medical insurance company or pharmacy providing the
proper verification for out-of-pocket medical expenses you anticipate for the next 12
months.
Other Assets Provide the value of the asset and/or statement of maturity of the asset.
Self-Employment A copy of your business account for the past twelve ( 12} months or profiUioss statement,
Schedule C and all pages of your signed Income Tax Return from the previous year.
Social Security A current printout or award letter from the Social Security Department. You can obtain one
SSA/SSI by calling the Social Security Office at (800} 772-1213. We cannot accept photocopies of
your checks. If benefits are reduced due to monies overpaid to you, we will need to know
the amount you owe the agency and the reason the overpayment occurred.
Student Verification All students applying separately from their parents who are under the age of 24, not
married, not a veteran, and do not have dependents must attach the "Student Verification
Information Sheet." The form can be obtained by picking it up from our office at 1331 Fulton
Mall, or downloading from our website: www.hafresno.org. Homepage-Popular Documents-
Click on "View all available forms" Scroll down to Housing Choice Voucher Tenant (Section
8}-Student Verification Form. Complete the form, attach to this packet and bring with you.
StudenUFinancial Aid / Adult students must attach verification of full-time & part-time student status, all financial aid
amounts and all scholarship amounts received.
TANF A current WHIS report from the Department of Social Services, or contact your worker.
If benefits are reduced we will need to know the reason.
UnemploymenUState Provide a copy of your award letter from the Employment Development Department (EDD)
Disability. office for any benefits being received, or which have been received within the past twelve (12}
months for any family member. If you have been denied unemployment benefits, you must
provide a copy of the denial letter. You can obtain one by calling the EDD office at (800} 300-
5616 or (800} 326-8937.
ELIGIBILITY 14 of14 RX PACKET (Rev. 03120113)