Case Management Forms   

2020 POINT IN TIME AGENCY FORM

2020 POINT IN TIME SURVEY FORM

Income guidelines:
To qualify, household income must meet the following income limit:
2019 Income Limits
ESG – At or below 30% of AMI
SSVF(Veterans) – At or below 50% of AMI

ESG Case File Sequence

Prescreen Forms
Please utilize the coordinated entry process.  All prescreens are required to be entered into Client Track.

Intake Documents
TCHSC Intake Form
New Housing plan- Budget

Client Consent Forms
Client Consent for Data Collection
Release of Information – Financial

Client Consent for Follow Up 

Rent Reasonableness
2020 Rent Reasonableness-MC
2020 Rent Reasonableness-SLC
2020 Rent Reasonableness-IRC

Utility Allowance
Indian River County Apartment
Indian River County Single-Family
St. Lucie County Apartment
St. Lucie County Mobile Home
St. Lucie County Single-Family
Martin County Apartment
Martin County Single-Family

Request for Funds
Request for Funds  

Inspection Forms
Habitability Standards
Lead-Based Screening

Landlord/Utility Documents 
Current Landlord Information
New Landlord Information
Utility Worksheet

W9 Form

SSVF SPECIFIC FORMS
Case File Tool

VETERAN STATUS
SSVF Pending Verification of Veteran Status – Fillable
Guide for Pending Verification of Veteran Status

HOUSING STATUS
Literally Homeless Certification – Fillable
Literally Homeless Self-Certification – Fillable
Self-Declaration of Housing Status – Fillable
HP Prevention Screening Form – COMPANION GUIDE
HP Screening Form – Fillable

INCOME/ASSET DOCUMENTATION
Verification of Income – Fillable
Self-Declaration of Income – Fillable
Asset Worksheet – Fillable
Income Calculation Worksheet-Fillable

STAFF CERTIFICATION
Staff Certification of Eligibility for SSVF Assistance-Fillable
Staff Re-Certification of Eligibility for SSVF Assistance-Fillable
Domestic Violence Certification Form-Fillable

CASE MANAGEMENT FORMS
Housing Habitability Standards Inspection Checklist-Fillable
Creating a Reasonable Housing Plan-Fillable
Referral Tracking Form-Fillable
Emergency Housing Assistance Verification-For Households with Dependents-Fillable
Emergency Housing Assistance Verification-For Single Veterans-Fillable
General Housing Stability Assistance Expense Tracker Form-Fillable
Rent Reasonableness Checklist

VA REFERRALS TO SSVF
HUD-VASH SSVF Referral Packet for RRH Only-Fillable
HUD-VASH SSVF Referral Packet – FAQ’s

CHECKLISTS
SSVF Program Exit Checklist-Fillable
SSVF Veterans Bill of Rights

OTHER SAMPLE FORMS
Shared Housing Fact Sheet
Shared Housing Roommate Interest Form
Housing General Conversion Process
Shared Housing General Roommate Matching Form
Shared Housing-Housing Preference Worksheet
Shared Housing Path Roommate Agreement
Shared Housing Rent Analysis Worksheet
Shared Housing Toolkit

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