office of policy, procedures and...

OFFICE OF POLICY, PROCEDURES AND TRAINING

James K. Whelan

Executive Deputy Commissioner

DHS-PB-2019-012

OFFICE OF POLICY, PROCEDURES AND TRAINING ‒

SUBJECT: Monthly Updates for DHS and DSS Forms

APPLICABLE TO: All DHS Staff, shelters and DHS facilities

ISSUED: June 6, 2019

PURPOSE The purpose of this policy bulletin is to announce Department of Homeless Services (DHS) and Department of Social Services (DSS) forms that have been posted on eDocs as newly created, revised, or removed from eDocs obsoleted.

NEW FORMS The following forms have been newly created and posted on eDocs:

• “Special One Time Assistance (SOTA) Demographic Sheet” (DHS-10e) is a new form used by Shelter Providers when submitting SOTA packets to the Human Resources Administration (HRA) Landlord Ombudsman Services Unit (LOSU) for approval.

• The following forms were created for the Client Responsibility process and will be discussed in further detail in a policy bulletin published at a later time:

▪ Statement of Client Rights and DHS Code of Conduct (DHS-22); ▪ Client Acknowledgement of Responsibility Form (DHS-22a); ▪ Collaborative Case Conference Notes (DHS-22b); ▪ Case Summary Form Instructions for Writing Client Case Summary

(DHS-22c); ▪ Client Responsibility Temporary Discontinuance of Shelter

Recommendation Form (DHS-22d); ▪ Notice to Provider of Sanction Denial (DHS-22e); ▪ DHS Review Committee Form (DHS-22f); ▪ Client Responsibility and Provider Accountability Documentation Checklist

(DHS-22g); ▪ Client Responsibility and Provider Accountability Documentation Checklist

for Providers (DHS-22L).

• “Emergency Contact Information” (DHS-24) is a new form that was created to capture emergency contact information for DHS families with children clients who reside in the shelter system. It is a DHS version of an OTDA sample form.

DHS-PB-2019-012


• “One Time Opportunity to Get a CityFHEPS Shopping Letter” (DSS-7v) is a new form created as a result of the CityFHEPS rule, which has a provision for clients who are not technically eligible for CityFHEPS, but had, as of 10/29/2018, an active SEPS, LINC or CityFEPS voucher. These individuals may be able to get a one-time CityFHEPS letter good for 120 days.

• “Apartment Walkthrough Outcome” (DSS-10c) form is required by the DHS Clearance and Apartment Review unit to provide landlords, brokers, and agents with information as to the results of the room or apartment walkthrough.

• “ROOM AND SRO REVIEW CHECKLIST” (DSS-10d) is a new form used by Shelter Providers when submitting SOTA packets to HRA LOSU for approval.

• “Unit Walkthrough Outcome” (DSS-10e) form is required by the DHS Clearance and Apartment Review unit to provide landlords/brokers/agents with information as to the results of the walkthroughs conducted by City staff.

• “Attestation of Compliance for Addressing Potential Lead Based Paint Hazards” (DSS-10f) form is for landlords of buildings built prior to 1978 attesting to the completion of addressing potential lead hazards identified through DSS Apartment/Room Walkthroughs.

• “Special Supplemental Assistance Fund Claim Request Form” (DSS-14) was created for CityFHEPS landlords to use when requesting reimbursement for damages or unpaid rent.

REVISED FORMS The following forms have been revised and posted on eDocs:

• The “Client Apartment Search Form” was renamed the “Client Housing Search Form” (DHS-6) and the language throughout the form was updated.

• “Tenant Contact Information” (DSS-8b) was revised to add “if applicable” after “BROKER INFORMATION”.

• The title “Landlord Statement of Understanding” was changed to “Landlord Information Form” and the CityFHEPS disclaimer was updated, if applicable, on the following forms:

▪ “CityFHEPS Approval Notice to Landlord” (DSS-8c); ▪ “CityFHEPS Landlord Information Form - Apartment Rentals” (DSS-8f); ▪ “CityFHEPS Landlord Information Form – Room and SRO Rentals”

(DSS-8g); ▪ “CityFHEPS Packet Cover Sheet – Shelter” (DSS-8h); ▪ “CityFHEPS Packet Cover Sheet – Community” (DSS-8i); ▪ “CityFHEPS Frequently Asked Questions for Landlords and Brokers”

(DSS-8j); ▪ “Change of Payee for CityFHEPS Payments” (DSS-8k);

DHS-PB-2019-012


▪ “CityFHEPS Packet Transmittal from DHS” (DSS-8L); ▪ “CityFHEPS Packet Transmittal from APS” (DSS-8m).

• The language of the “Unit Hold Incentive Voucher” (HRA-145) was completely revised.

• The following FHEPS forms were revised, as follows:

▪ “FHEPS A DEMOGRAPHIC SHEET” (HRA-146m) to include the correct form number of the “Apartment Review Checklist” (DSS-10a);

▪ “FHEPS B DEMOGRAPHIC SHEET” (HRA-146n) to add a check box for “Proof of Apartment/Room Preclearance” in the Did you include the following? section, include the correct form number of the “Apartment Review Checklist” (DSS-10a), and add a Supervisory Review section on page 2.

REQUIRED ACTION DHS staff and directors of shelters, safe havens, and drop-in centers must ensure that only the latest versions of forms (available on DHS intranet) are used and that all previous versions of the forms are removed from circulation and recycled. Effective Immediately

ATTACHMENTS: DHS-6 DHS-6 (S) DHS-10e DHS-22 DHS-22 (S) DHS-22a DHS-22a (S) DHS-22b DHS-22b (S) DHS-22c DHS-22d DHS-22e DHS-22f DHS-22g DHS-22L

Client Housing Search Form (04/29/2019) Client Housing Search Form (Spanish) (04/29/2019) Special One Time Assistance (SOTA) Demographic Sheet (06/06/2019) Statement of Client Rights and DHS Code of Conduct (04/01/2013) Statement of Client Rights and DHS Code of Conduct (Spanish) (04/01/2013) Client Acknowledgement of Responsibility Form (04/01/2013) Client Acknowledgement of Responsibility Form (Spanish) (04/01/2013) Collaborative Case Conference Notes (04/29/2019) Collaborative Case Conference Notes (Spanish) (04/29/2019) Case Summary Form Instructions for Writing Client Case Summary (06/06/2019) Client Responsibility Temporary Discontinuance of Shelter Recommendation Form (06/06/2019) Notice to Provider of Sanction Denial (06/06/2019) DHS Review Committee Form (06/06/2019) Client Responsibility and Provider Accountability Documentation Checklist (06/06/2019) Client Responsibility and Provider Accountability Documentation Checklist for Providers (06/06/2019)

DHS-PB-2019-012


DHS-24 DHS-24 (S) DSS-7v DSS-7v (S) DSS-8b DSS-8c DSS-8f DSS-8g DSS-8h DSS-8i DSS-8j DSS-8k DSS-8L DSS-8m DSS-10c DSS-10d DSS-10e DSS-10f DSS-14 HRA-145 HRA-146m HRA-146n

Emergency Contact Information (05/22/2019) Emergency Contact Information (Spanish) (05/22/2019) One Time Opportunity to Get a CityFHEPS Shopping Letter (05/14/2019) One Time Opportunity to Get a CityFHEPS Shopping Letter (Spanish) (05/14/2019) Tenant Contact Information (05/01/2019) CityFHEPS Approval Notice to Landlord (06/06/2019) CityFHEPS Landlord Information Form – Apartment Rentals (06/06/2019) CityFHEPS Landlord Information Form – Room and SRO Rentals ((06/06/2019) CityFHEPS Packet Cover Sheet – Shelter (06/06/2019) CityFHEPS Packet Cover Sheet – Community (06/06/2019 CityFHEPS Frequently Asked Questions for Landlords and Brokers (06/06/2019) Change of Payee for CityFHEPS Payments (06/06/2019) CityFHEPS Packet Transmittal from DHS (06/06/2019) CityFHEPS Packet Transmittal from APS (06/06/2019) Apartment Walkthrough Outcome (05/10/2019) ROOM AND SRO REVIEW CHECKLIST (05/10/2019) Unit Walkthrough Outcome (05/14/2019) Attestation of Compliance for Addressing Potential Lead Based Paint Hazards (05/14/2019) Special Supplemental Assistance Fund Claim Request Form (05/13/2019) Unit Hold Incentive Voucher (06/06/2019) FHEPS A DEMOGRAPHIC SHEET (06/06/2019) FHEPS B DEMOGRAPHIC SHEET (06/06/2019)

DHS-6 (E) 04/29/2019 (page 1 of 2) LLF

CLIENT HOUSING SEARCH FORM

We want you to return to safe and suitable housing in the community as soon as possible. You must view at least three (3) units each week to get the greatest benefit from your housing search. Fill out this form for each unit that you view, and give the form to your housing specialist or case manager. The completed form is proof that you are complying with the housing search requirement of your Independent Living Plan.

I, , viewed the following apartment/room:

Address:

Apartment/Room Number: Floor:

City: State: Zip Code:

Date of unit viewing: / /

Broker Name: Phone Number:

Landlord Name: Phone Number:

Total # rooms: Total # bedrooms: Total # baths: Elevator? Yes No

Instructions: Check one box belowI will accept this apartment/room if the landlord/broker offers it to me.My rent contribution will be $ .

I am rejecting this apartment/room for the reason(s) listed below. I understand that if I do not accept this apartment/room, without a valid reason, it may lead to a loss of shelter.__________________________________________________________________________________________________________________________

Client Signature Print Name Date

Preferred Name Pronouns

FOR STAFF USE ONLY If the client rejected the housing unit, was the rejection reasonable? Yes No If no, why not?

Shelter Staff (print name): Date Added to Case Record:

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DHS-6 (E) 04/29/2019 (page 2 of 2) LLF

THINGS TO LOOK FOR WHEN VIEWING A UNIT

When viewing a unit, here are some things you should look for. If you find a unit that you would be willing to accept, except that the unit needs minor repairs, talk to the landlord/broker and your case manager or housing specialist. They will help make sure the repairs are made before you move in.

Heat and hot water are included in the rentAsk the landlord or broker if heat and hot water are included. If they say they are included, when you sign the lease, make sure the lease says so too.If heat and hot water are not included in the rent, you will have to pay for them yourself, which can be expensive, especially in the winter.

There is at least one window in the living room and every bedroom.

The smoke detector and carbon monoxide detector are visible.

Window guards are in place, if you have a child age 10 or younger.

There is one electrical outlet in each room.

There are no exposed wires.

There is no visible peeling paint, and rooms are uniformly painted.

There is no visible mold.

There are no holes in the walls.

The stovetop, oven and refrigerator are present.

There is running water in the bathroom and kitchen. The bathroom and kitchen are accessible to all occupants.

Toilet ─ (Flush)Faucet ─ (Check for leaks)Tub/shower ─ (No stoppage)Sink ─ (Check for leaks)

The doors open and close properly and provide secure privacy.

The lights work. Typically, electricity is NOT included in the rent. You will be responsible for paying electricity after you move in.

The building hallways are free of garbage and well-lit.

The door to the building was locked.

DHS-6 (S) 04/29/2019 (page 1 of 2) LLF

FORMULARIO PARA BÚSQUEDA DE APARTAMENTO DEL CLIENTE

Nosotros deseamos que usted y su familia vuelvan a una vivienda segura y adecuada en la comunidad, tan pronto sea posible. Usted debe ver por lo menos tres (3) apartamentospor semana para obtener el mayor provecho de la búsqueda de vivienda. Rellene este formulario cada vez que vea apartamento y entréguelo a su especialista de vivienda o administrador del caso. El formulario rellenado es prueba de que usted está cumpliendo con el requisito de búsqueda de apartamento de su Plan de Vivienda Independiente.

Yo, , he visto el siguiente apartamento/ habitación:

Dirección:

Número de apartamento/habitación: Piso:

Ciudad: Estado:Código Postal:

Fecha en que vio el apartamento: / /

Nombre del agente: Núm. telefónico:

Nombre del arrendador: Núm. telefónico:

Núm. total de cuartos:

Núm. total de dormitorios:

Núm. total de baños: ¿Hay ascensor? Sí No

Instrucciones: Marque una de las siguientes casillasYo aceptaré este apartamento/habitación si el arrendador/agente inmobiliario me lo ofrece. Mi contibución para el alquiler será de$ .

Rechazo este apartamento/habitación por las razones listadas a continuación. Comprendo que si no acepto este apartmento/habitación,sin tener razón válida, esto podría resultar en la pérdida del refugio._________________________________________________________________________________________________________________________

Firma del cliente/la clienta Nombre en letra de molde Fecha

Nombre preferido Pronombres

FOR STAFF USE ONLY If the client rejected the housing unit, was the rejection reasonable? Yes No If no, why not?

Shelter Staff (print name): Date Added to Case Record:

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DHS-6 (S) 04/29/2019 (page 2 of 2) LLF

LO QUE DEBE TENER EN CUENTA A LA HORA DE VER APARTAMENTO

He aquí algunas de las cosas que usted debe tener en cuenta a la hora de ver apartamento. Si encuentra algun apartamento que estaría dispuesto(a) a aceptar, salvo a que el apartamento necesita pequeñas reparaciones, hable con el arrendador/agente y con su administrador de caso o especialista de vivienda. Ellos se asegurarán de que las reparaciones se lleven a cabo antes de que usted mude al apartamento. Verifique si:

La calefacción y el agua caliente están incluidas en el alquilerPregunte al arrendador o agente inmobiliriario si la calefacción y el agua caliente están incluidos. En caso afirmativo, asegúrese al usted firmar el contrato de arrendamiento, de que el contrato así lo indique también.Si la calefacción y el agua caliente no están incluidas en el alquiler, usted tendrá que pagarlas por cuenta propia, lo cual puede resultar caro, especialmente en el invierno.

Hay por lo menos una ventana en la sala de estar y en cada dormitorio.

El detector de humo y el detector de monóxido de carbono están a la vista.

Hay resguardos de ventana instalados, en caso de tener niños de 10 años o menores.

Hay enchufe eléctrico en cada cuarto.

Hay alambres expuestos.

Hay pintura descascarada y los cuartos están pintados de manera uniforme.

Hay moho visible.

Hay huecos en las paredes.

Hay estufa, horno y refrigerador.

Hay agua potable en el baño y en la cocina. Si todos los ocupantes tendrán acceso al baño y a la cocina.

El inodoro ─ (descargue el inodoro)El grifo ─ (sin escape de agua)La bañadera/ducha ─ (sin obstrucción en el desagüe)El fregadero ─ (sin escape de agua)

Las puertas se abren y cierran y si proveen seguridad y privacidad.

Las luces funcionan. Normalmente, la electricidad NO está incluida en el alquiler. Usted será responsable de pagar la electricidad tras mudarse al apartamento.

Los pasillos del edificio están libres de basura y están bien iluminados.

La puerta del edificio tiene cerradura.

DHS-10e (E) 06/06/2019

SPECIAL ONE TIME ASSISTANCE (SOTA) DEMOGRAPHIC SHEET

Facility Facility Code

Facility Staff Contact

Facility Staff Telephone Number Facility Staff Email

Program Administrator Program Analyst

CLIENT’S INFORMATION

Client’s Name

Social Security Number CARES Case Number

Did you include the following?

Copy of Lease

Income/Employment Verification

Residency Letter

Landlord Request Letter for Special One Time Assistance Program (HPA-71)

Landlord W-9

Landlord Proof of Ownership (Deed)

Security Voucher (W-147N)

Broker’s Request for Enhanced Fee Payment by Check (HRA-121)

Copy of Current Broker’s License

Payee Designation Form

Proof of Apartment/Room Preclearance (NYC only)

Apartment Review Checklist (NY) (NJ) (DSS-10a)

Photos of unit (unless DSS-10a also submitted)

Certificate of Habitability (East Orange only)

Request for Emergency Assistance, Additional Allowances, or to Add a Person to the Cash Assistance Case (W-137A)

SOTA Program Participant Agreement (DHS-10)

SOTA Landlord Agreement (DHS-10a or DHS-10c)

Comments:

SUPERVISORY REVIEW (Director of Social Services or higher)

Name Title

Email Address Telephone Number

Signature Date

DHS-22 (E) 04/01/2013 (page 1 of 4) LLF

Statement of Client Rights and DHS Code of Conduct

Shelter Name: __________________________________________ Date: _____/ _____/ ____

Last Name:

First Name: Middle Initial:

Social Security Number: Date of Birth: CARES ID Number:

The Statement of Client Rights and DHS Code of Conduct sets forth the requirements for staying in short-term emergency housing (“shelter”). Since shelter is not a home, but rather a stepping stone to housing in the community, there are certain requirements that you must meet while in shelter. These requirements ensure that shelters are a safe and respectful place for you and other shelter clients to reside temporarily and that you work with staff to exit shelter for housing in the community as quickly as possible. While in shelter, your rights include:

1. The right to exercise your civil rights and religious freedoms; 2. The right to have your personal, financial, social, and medical information kept

confidential by DHS and shelter staff; 3. The right to meet and have written communications with your legal representatives in

private; 4. The right to receive courteous, fair and respectful treatment; 5. The right to remain in the shelter, and not be involuntarily transferred or discharged

except in accordance with State regulations and the DHS procedures implementing those regulations;

6. The right to present grievances on behalf of yourself and other residents to your shelter or DHS without fear of retaliation and to receive a timely response;

7. The right to manage your own finances; 8. The right to leave and return to the shelter in accordance with the posted curfew; 9. The right to send and receive mail without interference or interception; 10. The right to be free from physical restraint or confinement; and 11. The right to end your shelter stay at any time.

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DHS-22 (E) 04/01/2013 (page 2 of 4) Department of Social Services

LLF Department of Homeless Services

Single acts of the following misconduct may lead to the loss of shelter (suspension and or sanction) if I:

1. Intentionally set a fire or vandalize property or equipment in or around the shelter premises;

2. Possess, sell, or use illegal drugs or alcohol in or around the premises; 3. Assault or physically attack another person, or exhibit threatening behavior which is

immediately dangerous to another person, or possess a weapon; 4. Am arrested for criminal activity including, but not limited to, trespassing, theft,

harassment, extortion, loan sharking, intimidation or victimization of residents or staff in or around the shelter premises;

5. Smoke in unauthorized shelter areas; 6. Commit acts that endanger the health and safety of self, others or which substantially

interfere with the orderly operation of the shelter. Single violations of the following may lead to the loss of shelter:

7. Since shelter is temporary, you must actively look for permanent housing and not unreasonably refuse or fail to accept any suitable housing that is found.

8. You must cooperate with and complete an assessment conducted by DHS or shelter staff.

9. You must cooperate in developing an Independent Living Plan (ILP) together with shelter staff.

Multiple violations of the following conduct standards may lead to the loss of shelter. However, in some cases, a single violation of a serious nature may also lead to the loss of shelter:

10. You must cooperate in carrying out and completing your ILP with shelter staff to achieve permanent housing. You must agree to and meet with shelter staff as required to discuss your progress in complying with your ILP.

11. You are required to keep your unit and the common areas of your unit/area clean and orderly. Shelter staff may conduct unannounced health and safety inspections of your unit on a weekly or more frequent basis. You must provide access to shelter staff for these inspections.

12. Each individual is limited to bringing two (2) bags of personal belongings into the shelter.

13. You may not bring in animals (unless you require the use of a service animal). 14. Only approved electronic devices are permitted in shelter (please see shelter for list of

approved devices). 15. You are not permitted to smoke or possess and/or consume alcoholic beverages

anywhere in the shelter.

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16. Excessive noise and disrespectful behavior towards shelter staff or fellow residents. 17. All residents must be properly dressed while on shelter grounds. You may not appear

outside your unit/area undressed or partially dressed at any time. 18. When directed, you are required to leave your unit/area and/or the building during fire

drills, evacuations, and any other safety exercises. 19. With the help of your caseworker, you are expected to take part in activities that will

help you find and obtain housing in the community such as applying for public assistance (“PA”) and other benefits for which you may be eligible, maintaining an open and active PA or other benefits case, working or searching for employment, participating in HRA and other job-training and employment programs, and looking for housing. If you remain in your unit without a valid reason, shelter staff can and will direct you to some activities, either in the shelter or elsewhere.

20. Shelter staff has the right to check your unit/locker/area daily. 21. Overnight stays outside of the shelter are not permitted unless pre-approved by shelter

staff. 22. Each individual must sign in and/or out when entering and/or exiting the shelter. You

may also be required to leave the unit keys with shelter security when leaving the shelter. All clients and client belongings are subject to search upon entering the shelter.

23. No visitors are permitted in the shelter except where specifically authorized and during established hours.

24. You may not change or add locks without authorization. 25. You must notify shelter staff whenever you are ill. 26. You will not engage in sexual activity in any single adult shelter. 27. You will not steal or enter any unauthorized areas.

Compliance with Public Assistance is a Requirement for Staying in Shelter:

28. You must apply for, and if eligible, maintain any benefits and resources applicable to you, including but not limited to an open and active Public Assistance (PA) case with HRA.

29. You must cooperate with HRA and DHS in determining your available resources, and you must apply for and use any benefits and resources that will reduce or eliminate the need for shelter.

30. If you have earned or unearned income, you must save the amount you and your case worker have agreed upon as set forth in your ILP.

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I am seeking shelter from the Department of Homeless Services. I have reviewed and have had the above “Statement of Client Rights and DHS Code of Conduct” explained to me and I understand it. These rights and responsibilities will help me achieve independence and find a permanent place to live.

IF I DO NOT FOLLOW THE STATEMENT OF CLIENT RIGHTS AND CODE OF CONDUCT:

1. I may be required to leave the shelter and have my shelter discontinued if I do notfollow this “Statement of Client Rights and DHS Code of Conduct”, even if I refuse tosign this document.

2. I will not have my shelter discontinued if I cannot obey the “Statement of Client Rightsand DHS Code of Conduct” due to a physical or mental impairment.

3. I have the right to challenge DHS’s decision to discontinue my shelter by requesting aNew York State Fair Hearing.

__________________________ __________________________ _________

Print Name Signature Date

STAFF:

I have explained this form to the client. Client refused to sign.

Print Name Signature

Date

DHS-22 (S) 04/01/2013 (page 1 of 4) LLF

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Declaración de Derechos del Cliente y Código de Conducta del DHS

Nombre del refugio: _________________________________________ Fecha: _____/ _____/ ____

Apellido:

Nombre: Inicial del 2do nombre:

Número de Seguridad Social: Fecha de nacimiento: Número de CARES ID:

La Declaración de Derechos del Cliente y Código de Conducta del DHS establece los requisitos para la estadía en un alojamiento de emergencia a corto plazo (“refugio”). Dado que el refugio no es un hogar sino el escalón que lleva a conseguir vivienda en la comunidad, existen ciertos requisitos que usted debe cumplir mientras se aloje en el refugio. Estos requisitos aseguran que el refugio sea un lugar seguro y de respeto para usted y otros clientes alojados provisionalmente y asegura que usted colabore con el personal para salir del refugio tan pronto sea posible, hacia una vivienda permanente en la comunidad. Durante la estadía en el refugio, sus derechos incluyen:

1. El derecho de ejercer sus derechos civiles y libertades religiosas; 2. El derecho de que el DHS y el personal del refugio mantengan la confidencialidad de

su información personal, económica, social y médica; 3. El derecho de reunirse y tener comunicación por escrito con sus representantes

legales en privado; 4. El derecho de recibir un trato cortés, justo y respetuoso; 5. El derecho de permanecer en el refugio y de no ser involuntariamente transferido o

despachado, excepto cuando sea conforme al reglamento del Estado y a los procedimientos del DHS que dan efecto a ese reglamento;

6. El derecho de presentar sus propias quejas y las de otros residentes, al refugio o al DHS sin temor de represalias y el derecho de recibir respuesta sin demora;

7. El derecho de administrar su propia economía; 8. El derecho de salir y regresar al refugio conforme al toque de queda establecido y

publicado; 9. El derecho de enviar y recibir correo sin interferencia ni intercepción; 10. El derecho de ser libre de restricciones físicas y de confinamiento y 11. El derecho de dar fin a su estadía en el refugio en cualquier momento.

DHS-22 (S) 04/01/2013 (page 2 of 4) Departamento de Servicios Sociales

LLF Departamento de Servicios para Personas sin Vivienda

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Un solo acto de las siguientes conductas indebidas podría llevar a la pérdida de la estadía en el refugio (suspensión y/o sanción)si yo:

1. Incendio o mutilo intencionalmente la propiedad o el equipo dentro o en los alrededores del recinto del refugio;

2. Poseo, vendo o uso drogas ilegales, o alcohol, dentro o en los alrededores del recinto del refugio;

3. Agredo o ataco físicamente a otra persona, o muestro conducta amenazante la cual represente peligro inmediato para otra persona, o poseo un arma;

4. Soy arrestado(a) por actividad delictiva incluyendo, sin limitarse al, traspaso, robo, acoso, extorción, préstamos ilegales, intimidación o victimización de los residentes o del personal, dentro o en los alrededores del recinto del refugio;

5. Fumo en áreas no autorizadas del refugio; 6. Cometo actos que pongan en peligro la salud y seguridad propia o de los demás, o

que interfieran en gran medida con el funcionamiento ordenado del refugio. Un solo incumplimiento de los siguientes podría llevar a la pérdida de la estadía en el refugio:

7. Dado que el refugio es temporal, usted tiene que buscar vivienda permanente de manera activa y no debe rechazar de forma irrazonable, ni debe dejar de aceptar una vivienda apropiada que encuentre.

8. Usted tiene que cooperar con el personal y llevar a cabo una evaluación realizada por el DHS o por el personal del refugio.

9. Usted tiene que cooperar en el desarrollo de un Plan de Vida Independiente (ILP, por sus siglas en inglés) en colaboración con el personal del refugio.

El incumplir varias veces las siguientes normas de conducta podría llevar a la pérdida de la estadía en el refugio. No obstante, en algunos casos, un solo incumplimiento grave también podría llevar a la pérdida de refugio:

10. Usted tiene que cooperar con el personal del refugio llevando a cabo y completando su plan ILP para conseguir vivienda permanente. Usted debe acordar y reunirse con el personal del refugio cuando sea requerido, para evaluar su progreso del cumplimiento de su plan ILP.

11. Se requiere que usted mantenga su área y las áreas comunes limpias y ordenadas. El personal del refugio podría llevar a cabo inspecciones no anunciadas, de salud y seguridad de su unidad, semanalmente o con más frecuencia. Usted tiene que dar acceso al personal del refugio para llevar a cabo estas inspecciones.

12. Cada persona puede traer al refugio un límite de (2) piezas de equipaje con sus efectos personales.

13. No puede traer animales (a menos que usted requiera animal de auxilio). 14. Solo se permiten dispositivos electrónicos aprobados (favor de ver la lista de

dispositivos aprobados del refugio). 15. No se le permite fumar, ni poseer o consumir bebidas alcohólicas en ningún lugar en el

refugio.



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16. Se prohíbe el ruido excesivo y la falta de respeto hacia el personal del refugio u otros residentes.

17. Todo residente debe vestirse apropiadamente dentro del recinto del refugio. Usted no debe salir de su unidad/área desnudo(a) o parcialmente vestido en ningún momento.

18. Al ser instruido, se requerirá que usted salga de su unidad/área o edificio durante simulacros de incendio, evacuaciones, o cualquier otro ejercicio de seguridad.

19. Con la ayuda de su trabajador de caso, se espera que usted participe en actividades que le ayudarán a encontrar y a obtener vivienda en la comunidad, como son el solicitar la asistencia pública (“PA”, por sus siglas en inglés) y otros beneficios para los cuales usted podría ser elegible, el mantener un caso abierto y activo de PA o de otros beneficios, trabajar o buscar empleo, participar en capacitación de trabajo de otros programas de empleo o de la HRA, y la búsqueda de vivienda. Si usted permanece en su unidad sin razón válida, el

personal del refugio le dirigirá a algunas actividades, ya sea en el refugio o fuera del mismo. 20. El personal del refugio tiene derecho a revisar a diario su unidad/locker/área. 21. Se prohíbe pasar la noche fuera del refugio sin aprobación previa del personal del refugio. 22. Cada persona tiene que firmar al entrar y salir del refugio. También se le podría exigir

entregar las llaves de su unidad al personal de seguridad cuando salga del refugio. Todo cliente y sus pertenencias quedan sujetos a ser registrados al entrar al refugio.

23. Se prohíbe recibir visitantes en su unidad excepto cuando se haya dado autorización específica y durante horas establecidas.

24. Usted no puede cambiar o añadir candados sin autorización. 25. Usted tiene que notificar al personal del refugio cuando esté enfermo(a). 26. Usted no tendrá relaciones sexuales en ninguno de los refugios para adultos solteros. 27. Usted no robará o entrará a ninguna área no autorizada.

El cumplimiento con la Asistencia en Efectivo es un requisito para la estadía en el refugio:

28. Usted debe solicitar y si es elegible, mantener todo beneficio y recurso que le corresponda, incluyendo, pero sin limitarse a, tener un caso abierto y activo de Asistencia en Efectivo (CA, por sus siglas en inglés) con la Administración de Recursos Humanos (HRA, por sus siglas en inglés).

29. Usted tiene que cooperar con la HRA y el DHS para determinar los recursos disponibles que tiene y debe solicitar, y utilizar, todo beneficio que reduzca o elimine la necesidad de permanecer en el refugio.

30. Si usted cuenta con ingreso salarial o no salarial, tiene que ahorrar la cantidad que usted y su administrador de caso hayan acordado y establecido en su plan de ILP.



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Estoy solicitando refugio proporcionado por el Departamento de Servicios para Personas sin Vivienda. He repasado, se me ha explicado y he entendido la “Declaración de Derechos del Cliente y Código de Conducta del DHS”. Estos derechos y responsabilidades me ayudarán a lograr la independencia y a encontrar un lugar permanente en donde vivir.

SI NO CUMPLO CON LOS REQUISITOS DE LA DECLARACIÓN DE DERECHOS DEL CLIENTE Y EL CÓDIGO DE CONDUCTA:

1. Se me podría exigir que salga del refugio y se podría discontinuar mi estadía en el refugio, si no obedezco esta “Declaración de Derechos del Cliente y Código de Conducta del DHS”, aun si me rehúso a firmar este documento.

2. No se discontinuará mi estadía en el refugio si no puedo obedecer la “Declaración de Derechos de Cliente y Código de Conducta del DHS”, debido a una deficiencia física o mental.

3. Tengo el derecho de contradecir la decisión del DHS de discontinuar mi estadía en el refugio solicitando una Audiencia Imparcial del Estado de Nueva York.

__________________________ __________________________ _________

Nombre en letra de molde Firma Fecha

STAFF:


Print Name Signature

Date

DHS-22a (E) 04/01/2013 (page 1 of 2) LLF

Client Acknowledgement of Responsibility Form

Shelter Name: _______________________________________________ Date: ____ / ______ / ______

Last Name:

First Name: Middle Initial:

Social Security Number: Date of Birth: CARES ID Number:

I am seeking Temporary Housing Assistance (“shelter”) from the Department of Homeless Services (“DHS”). I have received a copy of the “Statement of Client Rights and DHS Code of Conduct”. I understand that I must comply with the “Statement of Client Rights and DHS Code of Conduct” explained in this document and by shelter staff. These responsibilities will help me to achieve independence and find a permanent place to live.

Listed below is a summary of the Client Responsibility rules (shelter staff will provide further details):

1. You are required to apply for, and if eligible, maintain any benefits and resources applicable to you, including but not limited to an open and active Public Assistance (PA) case with HRA.

2. I must participate in developing, carrying out, and completing a service plan known as the “Independent Living Plan” (ILP).

3. I will seek and accept housing other than emergency shelter.

4. I must follow shelter rules and avoid behavior that places other clients or shelter staff at risk.

5. I will not have my shelter discontinued if I am unable to obey Client Responsibility rules due to a physical or mental condition or illness.

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DHS-22a (E) 04/01/2013 (page 2 of 2) Department of Social Services LLF Department of Homeless Services

CLIENT:

I have read and have had this form explained to me. I understand that I may be told to leave the shelter if I do not comply with the “Statement of Client Rights and DHS Code of Conduct” even if I refuse to sign this form.

Print Name

Signature Date

STAFF:


Print Name

Signature Date

Listed below is what may happen if I do not follow the rules of Client Responsibility:

1. I may have to leave the shelter if I am able to obey the rules and I choose not to do so.

2. I will have the right to challenge DHS’s decision to discontinue my shelter by requesting a New York State Fair Hearing.

3. If the Fair Hearing Judge agrees with DHS’s decision to discontinue my shelter, I will have to leave the shelter for a period of 30 days or until I decide that I will obey the rules, whichever period of time is longer.

4. I must follow the “Statement of Client Rights and DHS Code of Conduct”.

DHS-22a (S) 04/01/2013 (page 1 of 2) LLF

Acuse de Recibo del Cliente del Formulario de Responsabilidades

Nombre del refugio: ______________________________________________

Fecha: _____/_____/_____

Apellido:

Nombre: Inicial:

Número de Seguridad Social: Fecha de nacimiento: Número de Identificación de CARES:

Estoy solicitando Asistencia para Vivienda Temporaria (“refugio”) de parte del Departamento de Servicios para las Personas sin Vivienda (“DHS”, por sus siglas en inglés). He recibido una copia de la “Declaración de los Derechos del Cliente y el Código de Conducta del DHS”. Entiendo que debo cumplir la “Declaración de los Derechos del Cliente y el Código de Conducta del DHS” explicados en este documento y por el personal del refugio. Estas responsabilidades me ayudarán a lograr la independencia y a encontrar un sitio permanente en donde vivir.

Listados a continuación vea un sumario de las reglas de Responsabilidades del Cliente. (El personal del refugio proveerá detalles adicionales.):

1. Se le exige a usted que presente solicitud, y si es elegible, que mantenga todos los beneficios y recursos que le correspondan, incluyendo, pero sin limitarse a, un caso abierto y activo de Asistencia Pública (PA, por sus siglas en inglés) con la HRA.

2. Debo participar en la elaboración, la implementación y la finalización de un plan de servicio conocido como el “Plan de Vivienda Independiente” (ILP, por sus siglas en inglés).

3. Buscaré y aceptaré otra vivienda aparte del refugio de emergencia.

4. Debo seguir las reglas y evitar conducta que ponga a otros clientes o al personal del refugio en riesgo.

5. Mi estadía en el refugio no será discontinuada si no puedo obedecer las reglas de las Responsabilidades del Cliente, debido a una condición física o mental o enfermedad.

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DHS-22a (S) 04/01/2013 (page 2 of 2) Departamento de Services Sociales LLF Departamento de Servicios para las Personas sin Vivienda

CLIENTE:

He leído y se me ha explicado este formulario. Entiendo que se me puede pedir que salga del refugio si no cumplo la “Declaración de los Derechos del Cliente y el Código de Conducta del DHS”, aun si me rehúso a firmar este formulario.

Nombre en letra de molde

Firma Fecha

PERSONAL:

He explicado este formulario al cliente. El cliente se rehúso a firmar.

Nombre en letra de molde

Firma Fecha

Se lista a continuación lo que puede suceder si no sigo las reglas de las Responsabilidades del Cliente:

1. Puede que tenga que salir del refugio si puedo seguir las reglas, pero opto por no seguirlas.

2. Tendré el derecho de cuestionar la decisión del DHS de discontinuar mi estadía en el refugio, si solicito una Audiencia Imparcial del Estado de Nueva York.

3. Si el juez de la Audiencia Imparcial está de acuerdo con la decisión del DHS de discontinuar mi estadía en el refugio, tendré que salir del refugio por un período de 30 días o hasta que yo decida obedecer las reglas, cual período sea el más largo.

4. Debo seguir la “Declaración de los Derechos del Cliente y el Código de Conducta del DHS ”.

DHS-22b (E) 04/29/2019 (page 1 of 2) LLF

Collaborative Case Conference Notes

Date: _____________

Client Preferred Name: ______________________________ Name: ______________________________ Pronouns: _________________________

Shelter Name: ______________________________

This form is a guide for what we will discuss at this collaborative case conference. The staff member will use the notes they take on this

form when they create your updated Independent Living Plan (ILP). You can use this form to write your notes of what was discussed.

Strengths and Barriers

STRENGTHS BARRIERS

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DHS-22b (E) 04/29/2019 (page 2 of 2) Department of Social Services


Goals and Actions

Goal Action/Task Who will support action/task? By when?

Individuals present at this collaborative case conference:

_________________________________ _________________________________ _________________________________

(Client) (Case Manager) (Housing Specialist)

_________________________________ _________________________________ _________________________________

(Director of Social Services) (Shelter Director) (DHS Representative)

_________________________________ _________________________________ _________________________________

(Client Service Provider or Representative)

DHS-22b (S) 04/29/2019 (page 1 of 2) LLF

Notas sobre la Conferencia del Caso de Colaboración

Fecha: _____________

Nombre Nombre del cliente: ___________________________ preferido: __________________________ Pronombres: _________________

Nombre del refugio: ______________________________

Este formulario es una guía de lo que trataremos durante la conferencia de caso de colaboración. El personal utilizará las notas que

tomen en este formulario al crear su actualizado Plan de Vida Independiente (ILP, por sus siglas en inglés). Usted puede servirse de

este formulario para tomar notas de lo discutido.

Puntos fuertes y obstáculos

PUNTOS FUERTES OBSTÁCULOS

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DHS-22b (S) 04/29/2019 (page 2 of 2) Departamento de Servicios Sociales


Metas y acciones

Meta Acción/tarea ¿Quién le apoyará con la acción/tarea? ¿Para qué fecha?

Las personas presentes en esta conferencia del caso de colaboración:

_________________________________ _________________________________ _________________________________

(Cliente) (Administrador del caso) (Especialista en vivienda)

_________________________________ _________________________________ _________________________________

(Director de servicios sociales) (Director del refugio) (Representante de DHS)

_________________________________ _________________________________ _________________________________

(Representante o proveedor

de servicios al cliente)

DHS-22c (E) 06/06/2019 (page 1 of 4)

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CASE SUMMARY FORM INSTRUCTIONS FOR WRITING CLIENT CASE SUMMARY

Section 1. Demographic Information Summarize demographics and list all current household members. Include current and prior shelter stays, and reason(s) for homelessness. Summarize any medical or mental health issues for any household member (specify if diagnosed or suspected, whether the client needs and/or receives services). Section 2. Strengths Identify client strengths and discuss how to build on them to overcome barriers. Think outside of the box. What is the client good at? What does the client identify as strengths and what do you see as strengths? Section 3. Barriers to Permanency Summarize current barriers to permanency (e.g., domestic violence, immigration status, unemployment, etc.) Note medical and/or mental health issues, as well as disability/access needs if they present a barrier to permanent housing. Section 4. Child Welfare Involvement Is there a history of child welfare involvement? If the client or household has an open case with OCSS or ACS (or in another jurisdiction), explain. Include caseworker names and contact information. (Skip if not applicable.) Section 5. Summary of Financial Resources, Benefits and Entitlements What earned and unearned income does the client or household have? What about liens, garnishments, etc.? Summarize financial resources:

• Public Assistance benefits (specify amount received in cash, SNAP, and if the client or household has Medicaid)

• SSI/SSD/survivors’ benefits (specify amount and recipient)

• Unemployment or Worker’s Compensation

• Employment Income (list names of employed clients, names of their employers, length of time employed, and pay

• Indicate if the client receives any other type of income (child support, legal settlement income, bank account)

• Discuss if the client has savings and follows DHS savings program requirements, as applicable

Section 6. Case Management Summary Summarize current service needs on the Independent Living Plan (ILP) and tasks the client or household must complete. Specify start and completion dates. Note participation in ILP meetings. Summarize your engagement with the client or household. For families with children, include school attendance/performance and child care. Section 7. Exit Strategy/Housing Search Discuss current housing options and the client’s efforts to look for and secure housing. Note the target shelter exit date and whether the client has recently viewed housing. Include subsidy information as applicable. Section 8. Compliance Summary Discuss how a client is or is not carrying out responsibilities. Specify name(s) of individuals involved if a family. Document all instances where the client does and/or does not fulfill responsibilities, and explain your ongoing efforts to engage the client or household in CARES. Section 9. Next Steps/Follow-Up Actions Required Lay out next steps and any other follow-up tasks. Section 10. Summary of Incident (if applicable) If writing the case summary based on a client or household’s involvement in an incident, summarize incident details. Include contacts made with other agencies such as NYPD, ACS, etc., about the case and any pending details. Review Prior To Submission Review the case summary for accuracy and completeness before sending to DHS. Check spelling and grammar.

DHS-22c (E) 06/06/2019 (page 2 of 4) Department of Social Services

Department of Homeless Services

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Shelter Name: _____________________________________ Facility Code: _____________________ Client or Head of Case Name: CARES ID: Origin Date: Date Arrived at Current Shelter: ______________________ Section 1. Demographic Information (add rows if needed)

Individual Name Date of Birth

Age Gender/ Gender Identity

Preferred Name & Gender Pronouns

Relationship to HOH (if applicable)

Client or Household History (Summarize demographics, reason(s) for homelessness, shelter history):

Medical/Mental Health History:

Section 2. Strengths

Section 3. Barriers to Permanency

Section 4. Child Welfare Involvement (if applicable)



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Section 5. Summary of Financial Resources, Benefits and Entitlements

Section 6. Case Management Summary

Section 7. Exit Strategy/Housing Search

Section 8. Compliance Summary

Section 9. Next Steps/Follow-Up Actions Required

Condition of Unit/Sleeping Area

Objectively describe the condition of the client’s unit or sleeping area (what do you see, hear, smell, etc.?). Note any deficiencies. Are repairs needed? If yes, describe. If a family with children, document adequacy of food for the family size as applicable, check that cribs are being used, etc.



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Incident Report(s)

If the client or member of the household has been involved in an incident requiring a case summary, summarize the incident details below and any follow-up steps required. Section 9. Summary of Incident (if applicable)

Completed By (Staff Name): ___________________________________________________

Title: ______________________________________________________________________

Date: _______________________

DHS-22d (E) 06/06/2019 (page 1 of 3)

CLIENT RESPONSIBILITY TEMPORARY DISCONTINUANCE OF

SHELTER RECOMMENDATION FORM

From:

Shelter Director’s Name:

Email Address:

Shelter Name:

Shelter Address:

Telephone Number:

I hereby request that the Temporary Housing Assistance (THA) benefits of the client listed above be temporarily

discontinued due to (Check appropriate box):

Failure to seek and accept permanent or other appropriate housing (complete Section 1)

Gross Misconduct (complete Section 2)

Violation of Independent Living Plan (ILP) Agreement two or more times (complete Section 3)

Failure to apply for and maintain an open Public Assistance case (complete Section 4)

Failure to comply with Income Savings Plan (ISP) (complete Section 5)

SECTION 1 ─ GROUND(S): FAILURE TO SEEK AND/OR ACCEPT PERMANENT HOUSING

1st Rejection 2nd Rejection 3rd Rejection

Indicate basis for non-compliance, i.e., failure to seek permanent housing and/or rejected suitable housing:

What evidence confirms that client was offered housing?

Name of Landlord/Housing Organization: Telephone Number:

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CLIENT IDENTIFICATION INFORMATION

Client Name Preferred Name Gender

Pronoun(s)

CARES ID

Number

Date

of Birth

Primary

Language

Client Acknowledgment of Responsibility Form

(CARF) (Attach Copy) Dated & Signed:

Statement of Client Rights and DHS Code of Conduct

(Attach Copy) Dated & Signed:

Does client have physical or mental health disability? Yes No

Was it previously documented? Yes No (If YES, please specify and attach documentation)

Physical Disability:

Mental Disability:

Any additional information to be taken into consideration? Yes No (If YES, please specify)

DHS-22d (E) 06/06/2019 (page 2 of 3) Department of Social Services Department of Homeless Services

SECTION 1 ─ GROUND(S): FAILURE TO SEEK AND/OR ACCEPT PERMANENT HOUSING (continued)

Type and Address of rejected housing:

How was housing suitability verified?

Please indicate client’s stated reason(s) for the non-compliance and efforts made to elicit compliance (attach

case file documentation):

Shelter staff has discussed the housing option with the client:

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SECTION 2 ─ GROUND(S): GROSS MISCONDUCT

Client has engaged in behavior that (1) endangered the health or safety of themself or others or (2) substantially and repeatedly interfered with the orderly operation of the shelter. Gross Misconduct constitutes acts of violence or criminal conduct, including, but not limited to: assault, arson, possessing or selling drugs, theft, robbery, etc.

Please describe the gross misconduct; include client’s stated reason(s) for their behavior, and efforts made to elicit compliance; attach a copy of case record including, when available, an NYPD, signed NYC DHS Incident Report, video and witness statements:

SECTION 3 ─ GROUND(S): VIOLATION OF THE ILP TWO OR MORE TIMES (at least 4 instances are needed)

Please indicate violations and include client’s stated reason(s) for the non-compliance and efforts made to elicit compliance (attach case file documentation) and attach First Notice of ILP with supporting documentation:

SECTION 4 ─ GROUND(S): FAILURE TO APPLY FOR AND MAINTAIN AN OPEN PUBLIC ASSISTANCE CASE

Please indicate the basis of the non-compliance and attach copies of any Notice of Fair Hearing decision; include client’s stated reason(s) for the non-compliance and efforts made to elicit compliance (attach case file documentation including PA referral):

DHS-22d (E) 06/06/2019 (page 3 of 3) Department of Social Services Department of Homeless Services

SECTION 5 ─ GROUND(S): VIOLATION OF THE INCOME SAVINGS PLAN

Please indicate violations and include client’s stated reason(s) for the non-compliance and efforts made to elicit compliance (attach case file documentation) and attach First Notice of ISP with supporting documentation::

SECTION 6 ─ SIGNATURES FROM SHELTER STAFF

Completed By (print name) Title

Signature Date

Reviewed By (print name) Title

Signature Date

SECTION 7 ─ DHS PROGRAM ADMINISTRATOR REVIEW AND DETERMINATION

Date Request Received: Does violation meet criteria for sanction? Yes No

Additional documentation needed:

Reason for denial:

Program Administrator (print name) Date Decision Rendered

Signature Date Shelter Notified

NOTICE TO PROVIDER OF SANCTION DENIAL

Client Name CARES ID Number

Preferred Name Gender Pronoun(s)

To:

Shelter Director’s Name

Shelter Name

Shelter Address Telephone Number

Email

DHS ADMINISTRATIVE REVIEW (Check Appropriate Box)

Program Administrator DHS Review Committee

Date Request Received Date Shelter Notified of Decision

1. Your request to discontinue the shelter of the above client has been denied.

2. This client will remain in your facility.

Reason for Sanction Denial:

Other (Specify Reason):

DHS Representative (Print Name) Title

DHS Representative Signature Date

Forward Original to Provider, (1) copy to file

DHS-22e (E) 06/06/2019

DHS-22f (E) 06/06/2019 (page 1 of 2)

DHS REVIEW COMMITTEE FORM

Documentation Checklist Attached? Yes No Date Request Received: ___________________

Case record complete? Yes No Date Request Received: ___________________

Noncompliance is due to medical condition or disability?

Yes No

Violation meets criteria for sanction? Yes No

Reason for Determination (Please answer Yes or No and describe in further detail):

Violation of ILP two or more times Yes No Behavior meets definition of Gross

Misconduct Yes No

Failure to seek or accept permanent

or other appropriate housing Yes No

Failure to apply for and maintain an

open Public Assistance (PA) case Yes No

Violation of the ISP Yes No

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Client Name: Preferred Name Gender

Pronoun(s) CARES ID Number:

To: Shelter Director’s Name:

Shelter Name:

Shelter Address Telephone Number

Email:

Other (specify):

Please provide further detail:

DHS-22f (E) 06/06/2019 (page 2 of 2) Department of Social Services Department of Homeless Services

Reviewer Information

Reviewed By (print name)

Signature Date Decision Rendered

Email Telephone Number













DHS-22g (E) 06/06/2019

CLIENT RESPONSIBILITY AND PROVIDER ACCOUNTABILITY DOCUMENTATION CHECKLIST

DHS Representative:_____________________________________________________ Date: ____________________

Shelter Name: __________________________________________________________

Client Name: ____________________________ Preferred Name: ____________ Gender Pronoun(s): ___________

REQUIRED DOCUMENTATION DATE

REQUESTED DATE

RECEIVED

Client Responsibility Temporary Discontinuance of Shelter Recommendation Form (DHS-22d)

Client Acknowledgment of Responsibility Form (CARF) (DHS-22a)

Statement of Client Rights and DHS Code of Conduct (DHS-22)

Shelter rules and responsibilities

Collaborative Case Conference Notes (DHS-22b) forms

ILPs stating requirement to seek and accept suitable housing

All relevant CARES case notes

Relevant documentation or reasonable accommodations concerning a medical condition and/or disability

Housing Placement Documentation

Appointment slips for housing viewings and interviews

Client Housing Search Form (DHS-6) for every viewing

Case Notes summarizing the appointment or interview

Documentation of the housing placement offer (e.g., lease, letter from landlord)

Case Notes documenting client's refusal to search for housing + active staff engagement

Case Notes documenting missed appointments + active staff engagement

Psychiatric Evaluation or Psychosocial Assessment

Case Notes: documenting appropriate case management and explanation about rights and responsibilities, as well as possible sanction

GENERAL DOCUMENTATION (IF APPLICABLE)

Domestic Violence information

Evidence of translation/interpretation if client's preferred language read is not English

Intake Assessment

Employment information

Public Assistance information

Case Summary

DHS-22L (E) 06/06/2019

CLIENT RESPONSIBILITY AND PROVIDER ACCOUNTABILITY DOCUMENTATION CHECKLIST FOR PROVIDERS

Shelter Representative:__________________________________________________ Date: ____________________

Shelter Name: __________________________________________________________

Client Name: __________________________ Preferred Name: ______________ Gender Pronoun(s): ___________

REQUIRED DOCUMENTATION DATE

REQUESTED DATE SENT

Client Responsibility Temporary Discontinuance of Shelter Recommendation Form (DHS-22d)

Client Acknowledgment of Responsibility Form (CARF) (DHS-22a)

Statement of Client Rights and DHS Code of Conduct (DHS-22)

Shelter rules and responsibilities

Collaborative Case Conference Notes (DHS-22b) forms

ILPs stating requirement to seek and accept suitable housing

All relevant CARES case notes

Relevant documentation or reasonable accommodations concerning a medical condition and/or disability

Housing Placement Documentation

Appointment slips for housing viewings and interviews

Client Housing Search Form (DHS-6) for every viewing

Case Notes summarizing the appointment or interview

Documentation of the housing placement offer (e.g., lease, letter from landlord)

Case Notes documenting client's refusal to search for housing + active staff engagement

Case Notes documenting missed appointments + active staff engagement

Psychiatric Evaluation or Psychosocial Assessment

Case Notes: documenting appropriate case management and explanation about rights and responsibilities, as well as possible sanction

GENERAL DOCUMENTATION (IF APPLICABLE)

Domestic Violence information

Evidence of translation/interpretation if client's preferred language read is not English

Intake Assessment

Employment information

Public Assistance information

Case Summary

DHS-24 (E) 05/22/2019 LLF

EMERGENCY CONTACT INFORMATION

Head of Household Name: ___________________________________ Unit Number: ___________

In case of emergency contact: Name:

Address:

Telephone Number:

Relationship:

Name:

Address:

Telephone Number:

Relationship:

I give permission for the person(s) named above to take care of my children in case of an emergency.

Head of Household Signature Date

Shelter Staff Signature Date

Emergency Medical Information (conditions, medications, provider name and telephone number):

DHS-24 (S) 05/22/2019 LLF

INFORMACIÓN DE CONTACTO PARA EMERGENCIAS

Nombre del jefe(a) del hogar: ______________________________ Número de unidad: _________

En caso de emergencia contacte a: Nombre:

Dirección:

Número de teléfono:

Parentesco:

Nombre:

Dirección:

Número de teléfono:

Parentesco:

Concedo el permiso para que la(s) persona(s) nombrada(s) arriba cuide(n) a mis hijos en caso de emergencia.

Firma del jefe/de la jefa de familia Fecha

Firma del personal del refugio Fecha

Información médica para emergencias (condiciones, medicamentos, nombre y teléfono del médico):

DSS-7v (E) 05/14/2019 LLF

Date: _______________________

Dear Client:

You may qualify for a one-time opportunity to get a CityFHEPS shopping letter!

A CityFHEPS shopping letter is used to find housing in the five boroughs of New York City. There are a number of factors that determine the rent you will pay. Some examples include your household size and the income of each household member.

In the past, you were eligible for rental assistance under the LINC, SEPS, or CITYFEPS program. Those programs were replaced by CityFHEPS.

You must fix the issues that are checked below within 30 days of getting this letter to get a CityFHEPS shopping letter:

_______ 1. You may be eligible for Cash Assistance but have not applied for Cash Assistance, or there are sanctions on your Cash Assistance case

_______ 2. The number of people in your shelter case is different from the number of people on your Cash Assistance case

_______ 3. DHS does not have the Social Security Number for the head of your household

If you fix the issues above within 30 days, you will get a CityFHEPS shopping letter.

You will then have an additional 120 days to find suitable housing using this one-time CityFHEPS shopping letter. You must submit a rental assistance application within those 120 days.

If you do not submit a rental assistance application, you will not be eligible for CityFHEPS.

This is the only time you may be able get a CityFHEPS shopping letter because of your previous LINC, SEPS, or CITYFEPS shopping letter.

Speak to your caseworker or housing specialist if your situation changes and you think you may qualify for CityFHEPS for other reasons.

Do you have a medical or mental health condition or disability? Does this condition make it hard for you to understand this notice or to do what this notice is asking? Does this condition make it hard for you to get other services at HRA? We can help you. Call us at 212-331-4640. You can also ask for help when you visit an HRA office. You have a right to ask for this kind of help under the law.

DSS-7v (S) 05/14/2019 LLF

Fecha: _______________________

Estimado(a) cliente:

¡Usted podría calificar para la oportunidad única de obtener una carta de búsqueda de vivienda de CityFHEPS!

La carta de búsqueda de vivienda de CityFHEPS se utiliza para encontrar vivienda en los cinco condados de la ciudad de Nueva York. Existe un número de factores que determinan el alquiler que usted pagará. Algunos ejemplos incluyen el número de integrantes del hogar y el ingreso de cada integrante del hogar.

Anteriormente, usted fue elegible para recibir asistencia de alquiler según el programa de LINC, SEPS o CITYFEPS. Esos programas fueron reemplazados por CityFHEPS.

Usted tiene que solucionar los asuntos marcados a continuación dentro de 30 días de haber recibido esta carta, para poder obtener una carta de búsqueda de vivienda de CityFHEPS:

_______ 1. Puede que usted sea elegible para la Asistencia en Efectivo pero no la ha solicitado o existen sanciones en su caso de Asistencia en Efectivo.

_______ 2. El número de personas que aparecen en su caso de albergue es distinto al número de personas que aparecen en su caso de Asistencia en Efectivo.

_______ 3. El Departamento de Servicios para Personas sin Vivienda (DHS, por sus siglas en inglés) no tiene el número de seguro social del/de la cabecilla del hogar.

Si usted soluciona los asuntos marcados arriba dentro de 30 días, usted obtendrá la carta de búsqueda de vivienda de CityFHEPS.

Usted luego tendrá 120 días adicionales para encontrar una vivienda adecuada utilizando esta carta única de búsqueda de vivienda de CityFHEPS. Usted tendrá que presentar la solicitud para la asistencia de alquiler dentro de esos 120 días.

Si no presenta la solicitud para la asistencia de alquiler, no será elegible para recibir CityFHEPS.

Esta podría ser la única vez que pueda obtener la carta de búsqueda de vivienda de CityFHEPS ya que anteriormente obtuvo una carta de LINC, SEPS o de CITYFEPS.

Comuníquese con el/la trabajador(a) del caso o con el/la especialista en vivienda si su situación cambia y si piensa que califica para CityFHEPS por otros motivos.

¿Padece usted una discapacidad o afección médica o psiquiátrica? ¿Le dificulta la misma entender o cumplir este aviso? ¿Le dificulta la afección recibir otros servicios de la HRA? Nosotros podemos prestarle ayuda. Llámenos al 212-331-4640. Usted también puede pedir asistencia al visitar las oficinas de la HRA. Conforme a la ley, usted tiene el derecho de solicitar este tipo de ayuda.

DSS-8b (E) 05/01/2019

Tenant Contact Information

TENANT INFORMATION

Name:

Phone Number:

Email:

Emergency Phone Number:

Emergency Contact Name/Type:

LANDLORD / MANAGEMENT COMPANY INFORMATION

Name:

Phone Number:

Email:

Payment Address:

BROKER INFORMATION (if applicable)

Name:

Phone Number:

DSS-8c (E) 06/06/2019

CityFHEPS Approval Notice to Landlord

Dear Landlord,

________________________________________, has been approved for CityFHEPS for the following period and

at the following address:

Effective date: __________________ End date: ___________________.

Address:

1. Approved Apartment Rent: $_________

2. CityFHEPS Rental Assistance Supplement Amount (which HRA will pay to you or your designated

payee): $_________

3. Remaining Rent (a portion of this may be paid by HRA): $_________

The tenant is responsible for paying you, the landlord or your designated payee, the Remaining Rent, minus any shelter allowance that HRA may be paying on the tenant’s behalf. The CityFHEPS Landlord Requirements are set forth in Chapter 10 of Title 68 of the Rules of the City of New York and can be found in the CityFHEPS Landlord FAQ, available at www.nyc.gov/dsshousing. Please refer to www.nyc.gov/dsshousing for more information. CityFHEPS is similar to the federal Section 8 program in that, subject to the availability of funding, it provides assistance, including rental assistance of specified amounts, to landlords and tenants who want to form a landlord–tenant relationship.

Any contractual relationship will be solely between each tenant participating in the program and each tenant’s landlord participating in the program.

http://www.nyc.gov/dsshousing


DSS-8f (E) 06/06/2019 (page 1 of 3)

CityFHEPS Landlord Information Form – Apartment Rentals

Unit Information

Address:

Name of Owner:

The unit indicated above (the “Unit”) is being rented for at least a one-year period beginning on

__________________________________ to: __________________________________ . (the “Rental Agreement Start Date”) (the “Program Participant”)

Please read the Information Form carefully, complete all applicable fields, and sign in the space at the

bottom.

Program Information

HRA will pay a portion of the monthly rent (“CityFHEPS Rental Assistance Supplement Amount”) on behalf of the

eligible CityFHEPS household to rent the Unit. The Program Participant is responsible for paying any portion of

the rent that is not covered by the CityFHEPS Rental Assistance Supplement Amount and their Cash Assistance

(CA) shelter allowance, if any. Any contractual relationship will be solely between each tenant participating in the

program and such tenant’s landlord participating in the program.

The CityFHEPS Landlord Requirements are set forth in Chapter 10 of Title 68 of the Rules of the City of New

York and can be found in the CityFHEPS Landlord FAQ, available at http://nyc.gov/dsshousing.

CityFHEPS is similar to Section 8 in that, subject to the availability of funding, it provides assistance, including

rental assistance in specified amounts, to landlords and tenants who want to form a landlord-tenant relationship.

(Turn page)

http://nyc.gov/dsshousing

DSS-8f (E) 06/06/2019 (page 2 of 3) Department of Social Services Human Resources Administration

Landlord Information

Please select one:

I am the Owner of the unit identified above.

I am the Registered Managing Agent for the unit identified above and have attached current proof of

registration with HPD.

I am authorized to sign this landlord information form and the lease on behalf of the owner of the unit

identified above and have attached proof of such authorization.

Payment Information

Checks should be made payable to _____________________________________________ on behalf of

__________________________________________.

(Owner)

Relationship of Payee to Owner: _______________________ Payee Phone Number: _______________________________ Checks should be mailed to the following address:

Address:


I understand that I will receive at least the first full month’s rent up front.

If the Program Participant is moving into a new unit using CityFHEPS, I understand that I will also receive the following up-front payments (choose one):

3 months of CityFHEPS Rental Assistance Supplement

OR


If the Unit is being rented with the assistance of a broker, I represent that: (a) The owner is not the broker.

(b) The owner will not receive any part of the broker’s fee directly or indirectly from the broker.

(c) The premises cannot be rented without the services of the broker below:

Broker:

License Number:

Address:

(Turn page)

DSS-8f (E) 06/06/2019 (page 3 of 3) Department of Social Services Human Resources Administration

Landlord Requirements

1. I understand that I must comply with the provisions of §27-2056.8 of Article 14 of the Housing

Maintenance Code relating to duties to be performed in vacant units, and agree to abide by the

requirements of Local Law 1 of 2004 to the extent they are applicable to the Unit. I must read the

attached "Fix Lead Paint Hazards: What Landlords Must Do and Every Tenant Should Know” and

provide/ agree to provide a copy of the New York City Department of Health and Mental Hygiene

pamphlet concerning lead-based paint hazards to the Program Participant.

2. I make the following representations:

a) I have the legal authority to rent out the Unit for the period covered by the lease or rental agreement.

b) The rent charged in the lease is at or below the legal rent, if any, for the Unit as established by

federal, state, or local law or regulations.

Attachment:

Fix Lead Paint Hazards: What Landlords Must Do and Every Tenant Should Know

Landlord Authorized Signature Date

Print Name and Title

DSS-8g (E) 06/06/2019 (page 1 of 3)

CityFHEPS Landlord Information Form – Room and SRO Rentals

Unit Information

Address:

Name of Owner:

The unit indicated above (the “Unit”) is being rented for at least a one-year period beginning on

__________________________________ to: __________________________________ . (the “Rental Agreement Start Date”) (the “Program Participant”)

Please read the Landlord Information Form carefully, complete all applicable fields, and sign in the space

at the bottom.

Program Information

HRA will pay a portion of the monthly rent (“CityFHEPS Rental Assistance Supplement Amount”) on behalf of the

eligible CityFHEPS household to rent the Unit. The Program Participant is responsible for paying any portion of

the rent that is not covered by the CityFHEPS Rental Assistance Supplement Amount and their Cash Assistance

(CA) shelter allowance, if any. Any contractual relationship will be solely between each tenant participating in the

program and such tenant’s landlord participating in the program.

The CityFHEPS Landlord Requirements are set forth in Chapter 10 of Title 68 of the Rules of the City of New

York and can be found in the CityFHEPS Landlord FAQ, available at http://nyc.gov/dsshousing.

CityFHEPS is similar to Section 8 in that, subject to the availability of funding, it provides assistance, including

rental assistance in specified amounts, to landlords and tenants who want to form a landlord-tenant relationship.

(Turn page)

http://nyc.gov/dsshousing

DSS-8g (E) 06/06/2019 (page 2 of 3) Department of Social Services Human Resources Administration

Landlord Information

Please select one:

I am the Owner of the unit identified above.

I am the Registered Managing Agent for the unit identified above and have attached current proof of

registration with HPD.

I am authorized to sign this landlord information form and the lease on behalf of the owner of the unit

identified above and have attached proof of such authorization.

Payment Information

Checks should be made payable to _____________________________________________ on behalf of

__________________________________________.

(Owner)

Relationship of Payee to Owner: _______________________ Payee Phone Number: _______________________________ Checks should be mailed to the following address:

Address:


I understand that I will receive at least the first full month’s rent up front.

If the Program Participant is moving into a room, I understand that I will receive the first 4 months’ rent in full up front except if the household receives a shelter allowance, my up front rent payments will consist of the first month’s rent in full plus the CityFHEPS rental assistance payment for the next 3 months.

If the Program Participant is moving into an SRO, I understand that, in addition to the first month's rent, I will receive the following up front payments (choose one):


OR


If the Unit is being rented with the assistance of a broker, I represent that:

(a) The owner is not the broker.

(b) The owner will not receive any part of the broker’s fee directly or indirectly from the broker.

(c) The premises cannot be rented without the services of the broker below:

Broker:

License Number:

Address:

(Turn page)

DSS-8g (E) 06/06/2019 (page 3 of 3) Department of Social Services Human Resources Administration

Landlord Requirements

1. I understand that I must comply with the provisions of §27-2056.8 of Article 14 of the Housing

Maintenance Code relating to duties to be performed in vacant units, and agree to abide by the

requirements of Local Law 1 of 2004 to the extent they are applicable to the Unit. I must read the

attached "Fix Lead Paint Hazards: What Landlords Must Do and Every Tenant Should Know” and

provide/ agree to provide a copy of the New York City Department of Health and Mental Hygiene

pamphlet concerning lead-based paint hazards to the Program Participant.

2. I make the following representations:

a) I have the legal authority to rent out the Unit for the period covered by the lease or rental agreement.

b) The rent charged in the lease is at or below the legal rent, if any, for the Unit as established by federal, state, or local law or regulations.

Room rentals only:

c) The individual’s move into the apartment will not result in more than three unrelated individuals residing in the apartment in violation of the Housing Maintenance Code.

d) DSS is not making payments on behalf of anyone who is no longer in the apartment.

e) No CityFHEPS tenants have moved from their original room to a different room within the apartment that did not have a walkthrough performed by the City.

f) DSS is not paying rent on behalf of anyone else for the room you are attempting to rent to a new tenant.

g) The Room is NOT in a unit subject to Rent Stabilization.

Attachment:

Fix Lead Paint Hazards: What Landlords Must Do and Every Tenant Should Know

Landlord Authorized Signature Date

Print Name and Title

DSS-8h (E) 06/06/2019 (page 1 of 2)

CityFHEPS Packet Cover Sheet – Shelter

Client’s Information

Client’s Name: _______________________________________ Social Security Number: ___________________

Agency Name: _______________________________________ Cash Assistance Case #: __________________

Staff Contact: _______________________________________ Staff Phone #: __________________________

Staff e-Mail: ______________________________________________________________________________

Program Analyst: _____________________________________ CARES ID: _____________________________

Program Administrator: ________________________________ Facility Code: ___________________________

Did you include the following mandatory documents?

DSS-7 or DSS-7b (“Shopping Letter”)

DSS-7a or DSS-7c (“Household Share Letter”)

Proof of last 30 days of Income (for everyone in the household 18+)

W-137A Request for Emergency Assistance

DSS-7p Program Participant Agreement

Lease or Rental Agreement for 12 months

Shelter Residency Letter

DSS-8b Tenant Contact Information

Landlord W9

Proof of Apartment/Room Preclearance

DSS-10a Apartment Review Checklist

Deed/Proof of Ownership

DSS-8f or DSS-8g (“Landlord Information Form")

Signed by managing agent or other authorized representative? If checked,

Proof of HPD Registration or

Authorization

W-147N Security Voucher

Check the rental type and associated forms included. Also check which landlord incentives apply, if any:

Room Rental?

DSS-8d Room Allocation Form

$500 Veteran bonus for landlords

Apartment/SRO Rental?

HRA-145 Unit Hold Incentive Voucher

Landlord bonus $________________

CityFHEPS Rental Assistance

Supplement

3 months OR 11 months

If a Broker was used, did you include the following documents?

HRA-121 Broker’s Request for Enhanced Fee Payment by Check Broker License (if broker fee)

Comments: _________________________________________________________________________________

(Turn Page)

DSS-8h (E) 06/06/2019 (page 2 of 2) Department of Social Services Human Resources Administration


Name Title

Email Address Telephone Number

Signature Date

DSS-8i (E) 06/06/2019 (page 1 of 2)

CityFHEPS Packet Cover Sheet - Community


Client’s Name: ______________________________________________________________________________

Social Security Number: ________________________________ Cash Assistance Case #: _________________

Agency Name: __________________________ Staff Contact: ________________________________________

Staff Phone #: __________________________ Staff e-Mail: _________________________________________

Did you include the following mandatory documents?


DSS-8e CityFHEPS Verification of Eligibility

DSS-7o or DSS-7q ("Application for CityFHEPS")





Proof of eligibility (veteran status, APS letter, eviction, transfer approval, vacate)


Landlord W9

Deed/Landlord Proof of Ownership




Authorization

W-147N Security Voucher (new units only)

Is the household remaining in place or moving to a new unit?

Remaining in Place

Arrears Documents (court stipulation, rent breakdown, etc.)

Emergency Assistance to Needy Families (EAF) Agreement to Repay Excess Shelter Arrears (W-147KK)

Emergency Safety Net Assistance (ESNA) Shelter Arrears Repayment Agreement (W-147N)

New Unit




Check the rental type and associated forms included. Also check which landlord incentives apply, if any:

Room Rental?


$500 Veteran bonus for landlords

Apartment/SRO Rental?


Landlord bonus $________________

CityFHEPS Rental Assistance

Supplement


(Turn Page)

DSS-8i (E) 06/06/2019 (page 2 of 2) Department of Social Services Human Resources Administration

Do any of the following situations apply?

HRA-146p Domestic Violence Action Form Broker? If checked,

HRA-121 Broker’s Request for Enhanced Fee Payment by Check

Broker License (if broker fee)

Comments:

DSS-8j (E) 06/06/2019 (page 1 of 4)

CityFHEPS Frequently Asked Questions for Landlords and Brokers

What is CityFHEPS?

CityFHEPS is a rental assistance supplement program to help individuals and families find and keep an

apartment, a room, or single room occupancy (SRO) unit. CityFHEPS consolidates seven subsidies into a

single program, designed to simplify and streamline the process for all New Yorkers, including landlords

and brokers, who serve as partners in our efforts to connect low-income New Yorkers to stable housing.

The program is administered by the Department of Social Services (DSS), which includes both the

Department of Homeless Services (DHS) and the Human Resources Administration (HRA).

CityFHEPS rent levels are indexed to annual NYC Rent Guidelines Board adjustments for one-year

leases and are slightly higher than previous City programs. If you house a tenant with CityFHEPS, you

will receive rent payments directly from DSS/HRA.

What are the benefits of participating in CityFHEPS for landlords and brokers?

Under CityFHEPS, you will receive:

Rents that are based on household size and indexed to annual NYC Rent Guidelines Board

adjustments for one-year leases.

For apartments and SROs: The option to receive the first month’s rent in full, plus the next three

(3) months’ rent supplement up front, or the first month’s rent in full plus the next 11 months’ rent

supplement up front.

For rooms: The first four (4) months’ rent in full up front except if the household receives a shelter

allowance. (If the household receives a shelter allowance, the landlord will receive the first

month’s rent in full plus the CityFHEPS rental assistance payment for the next 3 months up front.)

Monthly rental assistance payments from DSS/HRA for up to five (5) years if your tenant

continues to meet eligibility requirements and you remain in compliance with program

requirements.

A timely and standardized apartment or room “preclearance.”

The following incentives may also be available:

A $4,300 landlord bonus at signing

A “unit hold” incentive equal to one month’s rent for landlords who agree to hold an apartment

while the housing packet is being processed

A broker’s fee up to 15% of the annual rent

For the most up-to-date information on the CityFHEPS program and benefits, please visit

www.nyc.gov/dsshousing.

(Turn Page)


DSS-8j (E) 06/06/2019 (page 2 of 4) Department of Social Services Human Resources Administration

How do I participate in the CityFHEPS program or find out more?

If you are a landlord or broker,

Find out more information about leasing an apartment with CityFHEPS by calling the Public

Engagement Unit’s Home Support Line at 929-221-0047 or filling out the online form at

http://nyc.gov/homesupportunit.

What is the maximum rent for apartments CityFHEPS tenants can lease?

How much will I receive from the supplement?

Part of the rent will be covered by the CityFHEPS rental assistance supplement. If the tenant has income,

they will also pay a portion of their income as rent.

The amount of a household’s CityFHEPS rental assistance supplement will depend on household

income, the number of people in the household, and the current CityFHEPS program maximum rent,

which is indexed to the annual rent adjustments of the NYC Rent Guidelines Board. The amount of the

household’s CityFHEPS rent supplement is decided when the household’s CityFHEPS application is

approved by DSS.

In general, the CityFHEPS rent supplement will not change during the first year of the program, except in

very limited circumstances.

What if I am offering a rented room or an SRO?

If you are offering a rented room, the maximum rent is $800, and the CityFHEPS rental supplement will

be the difference between the actual rent (up to $800) and the tenant’s contribution ($50 or their monthly

shelter allowance, whichever is greater). If you are offering an SRO, the maximum rent is $1,047, and the

CityFHEPS rental supplement will be the difference between the actual rent and the tenant’s contribution

(30% of the household’s monthly gross income or the maximum monthly shelter allowance, whichever

is greater). Heat, hot water, electricity and, if the stove is not electric, cooking gas, must be included in

the rent.

What is the unit approval and leasing process?

There are several steps to the unit approval and leasing process.

Once a tenant has identified a unit, the tenant’s housing specialist or case worker will begin the pre-

clearance process, which is conducted by DSS.

Then, the unit and building must be clear of a specific set of violations, and a physical walkthrough is

scheduled to review the unit. If the unit passes the walkthrough, the tenant’s housing specialist or case

worker will prepare the housing packet – including the request for a unit hold payment referenced earlier

– and also schedule a lease signing for you and the tenant.

To learn more about what is required for the preclearance and walkthrough, you can look at the Website

Clearance Checklist, Apartment Review Checklist, and the Apartment Review Checklist Guidance

available on www.nyc.gov/dsshousing.

(Turn Page)

CityFHEPS Program Maximum Apartment Rent Chart (as of October 2018)

Household Size 1 2 3 or 4 5 or 6 7 or 8 9 or 10

Maximum Rent $1,246 $1,303 $1,557 $2,010 $2,257 $2,600



What is the unit approval and leasing process? (continued)

The lease must be signed by both you and the tenant in order for the packet to be reviewed. The lease

must reflect the complete address of the unit, including the unit number.

Once the packet is complete and submitted, it undergoes a final review by DSS. If the packet is approved,

a key and check exchange is scheduled by the tenant’s housing specialist or case worker. At the key and

check exchange, you must provide the tenant with keys for the unit they were shown, which must be the

same as the unit indicated on the lease. At the key and check exchange, you will receive several checks

for any approved unit hold payment and the first several months of rent for the unit. You will also be

provided with the security voucher.

Tenants must renew their participation in the CityFHEPS program annually. DSS will recalculate the

tenant contribution of a participant based on their current income when they renew. Although CityFHEPS

landlords are not required to renew their tenants in the program unless otherwise required to do so by

law, a landlord who does not offer their CityFHEPS tenant a renewal lease will not be eligible for financial

incentives to place another tenant in the same unit, unless there was good cause not to renew.

What help is available once my tenant moves in?

For program information and payment inquiries, contact the HRA Rental Assistance Call Center, Monday-

Friday from 9 AM to 5 PM at 929-221-0043.

Are there additional CityFHEPS requirements?

Under the CityFHEPS rules, side deals are strictly prohibited. Landlords must not demand, request, or

received any amount above the rent or reasonable fees as stipulated in the lease or rental agreement

regardless of any changes in household composition.

Additionally:

When HRA issues monthly CityFHEPS rental assistance payments and monthly shelter

allowance payments (if any) in full by the final day of the month, these payments will be deemed

timely paid towards the CityFHEPS unit’s rent for that month, regardless of any provisions in the

CityFHEPS unit lease to the contrary.

Landlords are required to accept the HRA security voucher in lieu of a cash security deposit and

may not request any additional security from the client.

Landlords must not move a household from one unit to another without the prior written approval

of both HRA and the household.

Landlords must notify HRA within 5 business days of learning that the household no longer

resides in the unit towards which CityFHEPS rental assistance is being applied.

Landlords must notify HRA within 5 business days if any legal proceeding affecting the program

participant’s tenancy is commenced.

Landlords must notify HRA promptly if the landlord, owner of the subject premises, or the

management company changes.

If the household no longer resides in a CityFHEPS unit, the landlord must return any payments

from HRA for any period of time the household was not residing in the unit.

Landlords must promptly return to the City any overpayments, including but not limited to monies

paid in error or made as a result of inaccurate, misleading or incomplete information submitted by

the landlord in connection with the CityFHEPS Program.

(Turn Page)


HRA will provide me with instructions on how to return any overpayments when such overpayments are

reported.

Notifications to HRA must be made in writing to:

Rental Assistance Programs NYC Human Resources Administration

150 Greenwich Street, 36th Floor New York, NY 10007

Landlords may be banned from participation in City rental assistance programs for violations of

any of the landlord requirements. Before placing a landlord on a disqualification list, HRA will

provide notice to the landlord and an opportunity for the landlord to object in writing.

The information in this fact sheet provides a general overview of the CityFHEPS program. It is not

intended to provide full details concerning the operation of the program.

CityFHEPS is similar to the federal Section 8 program in that, subject to the availability of funding,

it provides assistance, including rental assistance of specified amounts, to landlords and tenants

who want to form a landlord–tenant relationship.

Any contractual relationship will be solely between each tenant participating in the program and

each tenant’s landlord participating in the program.

DSS-8k (E) 06/06/2019 (page 1 of 2)

Change of Payee for CityFHEPS Payments

The person who completes this form must be either:

1. The managing agent;

2. The person who signed the original “CityFHEPS Landlord Information Form”;

OR

3. The current owner.

1. Tenant Information

Name: __________________________________________ Program Type: ____________________________

Address: __________________________________________________________________________________

2. Change of Payee Reason and Effective Date

Reason for Payee Change (check which box applies):

Change in ownership (please provide bill of sale, deed, or other proof of ownership change, if not

provided already)

Change in Management (please provide the following if different from the payee information below):

Management Company Name: _________________________________________________________

Address: ______________ _ Apt. or Suite #: _______

City: __ State: ______________ Zip Code: __________________

Other: Please explain reason for payee change. ___________________________________________

__________________________________________________________________________________

Effective Date of Payee Change: __________________________

3. Payee Name (checks will be made payable to the designated payee on behalf of the owner)

Payee Name:

4. Payee Information

Name of Contact Person (if Payee is an Entity):

Email: Phone #:

(Turn Page)

DSS-8k (E) 06/06/2019 (page 2 of 2) Department of Social Services Human Resources Administration

5. Mailing Address for Checks

Address: _ Apt. or Suite #:


6. Payee’s Mailing Address (if different from Mailing Address for Checks above)

Address: _ Apt. or Suite #:


7. Landlord Statement

Complete and sign the statement below:

Please be advised that I ___________________________________________________________, hereby authorize (print landlord name)

______________________________________________________________ to receive payment for the apartment (print payee name)

located at: ___________________________________________________________________________________ (print full address)

for the above-referenced tenant.

Landlord Name: ______________________________________________________________________________

Landlord Signature: ____________________________________________________________________________

DSS-8L (E) 06/06/2019 (page 1 of 2)

CityFHEPS Packet Transmittal from DHS

Date: ______________________ CA Case #: ______________________

To: RAP

From: _______________________________________________ Telephone #: ______________________

(OCR Staff Name)

For: CityFHEPS Applicant

________________________________________________ ______________________

(Applicant Name) (Social Security Number)

REQUESTING THE FOLLOWING:

CityFHEPS Rental Assistance Supplement? 3 months 11 months

Requesting Furniture? Yes No

Security Voucher? Yes No

Landlord Bonus? Yes No

Monthly Rent: $ _____________

$500 Veteran Bonus? Yes No

Unit Hold? Yes No

Broker’s Fee? Yes No

DOCUMENTS ATTACHED:







Shelter Residency Letter


Landlord W9



Deed/Proof of Ownership




Authorization




DSS-8d Room Allocation Form (Room Rental only)

HRA-145 Unit Hold Incentive Voucher (Apartments/SROs Only)

(Turn page)

COMMENTS:

__________________________________________________________________________________________

__________________________________________________________________________________________

DSS-8L (E) 06/06/2019 (page 2 of 2) Department of Social Services Human Resources Administration

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

DSS-8m (E) 06/06/2019 (page 1 of 2)

CityFHEPS Packet Transmittal from APS

To: RAP Date: _____________________

APS Staff Name: ___________________________________________ Telephone: _____________________

CityFHEPS Applicant Name: __________________________________

Social Security Number: _________________________ CA Case : _____________________

REQUESTING THE FOLLOWING:

Request Type: To Move To Stay

Housing Type: Apartment SRO Room

CityFHEPS Rental Assistance Supplement?


Monthly Rent: $ _____________

Arrears Amount: $_____________

Requesting Furniture? Yes No

Security Voucher? Yes No

Landlord Bonus? Yes No

Unit Hold? Yes No

Broker’s Fee? Yes No

DOCUMENTS ATTACHED:

Client’s Documents


Other Documents (ID, Birth Certificate, Social Security Card)


APS W-101 (Notice of Eligibility Determination Form)


HRA-146p Domestic Violence Action Form

CityFHEPS Forms

DSS-8e (CityFHEPS Verification of Eligibility)

DSS-7o or DSS-7q ("Application for CityFHEPS")





W-147H Shelter Arrears Repayment Agreement

Arrears Document (Landlord Breakdown)

Court Documents (Stipulation, Eviction, Filing, Marshal’s Notice)

Move Package (Landlord & Broker Forms)


Landlord W9

Deed/Landlord Proof of Ownership



Proof of HPD Registration or Authorization


(Room Rental only)


HRA-145 Unit Hold



(Turn page)

DSS-8m (E) 06/06/2019 (page 2 of 2) Department of Social Services Human Resources Administration

COMMENTS:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

DSS-10c (E) 05/10/2019 (page 1 of 2)

APARTMENT WALKTHROUGH OUTCOME

Reason for Review: Apartment Walkthrough

Building Address: __________________________________________________________________________________

Apartment Number: ___________________ Floor: ____________________ Walkthrough Date: __________________

THE ABOVE UNIT: PASSED FAILED NO ACCESS TO UNIT GIVEN

If applicable, list the reason(s) why the Unit failed. Include the letter of each failed item in its appropriate section below.

1. Interior of Building: ________________________________________________________________________

2. Hallway and Apartment or House: ____________________________________________________________

3. Overall Apartment/House: _____________________________________________________________________

4. Bathroom: _________________________________________________________________________________________________

5. Kitchen: ___________________________________________________________________________________________________

6. Electrical: ________________________________________________________________________________

8. Approval (provide a detailed description for items 8a & 8b, if applicable): ______________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Note: Section 7. Accessibility is not included above because it is intended for information gathering only.

An abbreviated list of each question from the Apartment Review Checklist (DSS-10a) appears on page 2 of this form.

Failed conditions will require an additional walkthrough. Please contact the party checked below when the unit is

ready. Provider DHS (choose DHS if any failed item is marked as ESCALATE on page 2)

Certification

I certify that I visited the property located at the address indicated above and that the information in this form has been

answered correctly to the best of my ability.

Person completing walkthrough (Print) Person completing walkthrough (Signature) Date

Name of your organization (Print)

Landlord/Landlord Representative Name (Print) Landlord/Landlord Representative (Signature)

(Turn page)

DSS-10c (E) 05/10/2019 (page 2 of 2) Department of Social Services Human Resources Administration

Section 1: Interior of building

1a. Stairs and halls not free of hazards

1b. Stairs and halls not free of excess garbage

1c. No clear path to egress

1d. Insufficient lighting

1e. No working mailbox/slot

1g. Fire exit is locked

1h. Fire exit is blocked

1i. No self-closing door

1j. No bell or buzzer

Section 3: Overall Apartment/House (continued) 3aa. Unit is in basement, cellar, or attic

(ESCALATE)

3ab. Unit can only be accessed through another unit

3ae. Porch or balcony has no railing

3af. Unit has dropped ceiling (ESCALATE)

3ag. Unit has potential illegal subdivision

(ESCALATE)

3ah. Unit temperature is not adequate

Section 2: Hallway and Apartment/House

2b. No window guards in hallway

2c. No window guards in unit

Section 4: Bathroom

4a. No running hot or cold water

4b. No freely flowing water

4c. Water is not clean or free of rust

4d. Toilet is not working

4e. No vent or operable window

4f. Bathroom has plumbing leaks

Section 3: Overall Apartment/House

3a. Unit under repair, renovation, or construction

3d. Fire escape window gate(s) cannot be opened

from the inside

3e. Window gate(s) has no FDNY stamp

3f. Door to room with fire escape window has lock

3g. Window(s) is not operable

3i. Window to ground is not lockable

3j. Unit has cracked, peeling, or loose paint

3k. Unit was constructed in 1978 or earlier

(ESCALATE)

3l. Unit is not free of vermin

3m.Unit is not free of leaks

3n. Floor not free of hazards

3o. Holes in walls, floors, or ceilings

3p. Sleeping rooms are not at least 80 sq ft & do

not include window or skylight

3q. Apartment door requires key to exit

3r. Smoke detector is not present or is more than 15 ft

from sleeping room entrance

3s. Smoke detector is not working

3t. Carbon monoxide detector is not present or is more

than 15 ft from sleeping room entrance

3u. Carbon monoxide detector is not working

3v. Unit does not have heat source in every room

3x. Radiator steam is visible (ESCALATE)

3y. Radiator is leaking (ESCALATE)

3z. Radiator is missing knob or valve (ESCALATE)

Section 5: Kitchen

5a. No running hot or cold water

5b. Water in sink is not clean after running

5c. No working oven

5d. No working stove

5e. Refrigerator rails and shelves are inadequate

5f. Refrigerator is not cold

5g. Freezer is not working

5h. No food storage space

5i. No meal preparation area

5j. Kitchen has plumbing leaks

5k. Stove or oven has grease build-up

5l. No working vent over stove or window in kitchen

Section 6: Electrical

6a. Sleeping rooms lack two outlets OR one outlet

plus one light fixture

6b. Outlets in kitchen and bathroom are not

GFCI outlets

6c. Fixtures and electrical devices are not secured or

lack plate covers

6d. Unit has exposed wires

6e. Unit has wires in or near standing water

Section 8: Approval

8a. Other issue

8b. Not approved for rent

DSS-10d (E) 05/10/2019 (page 1 of 7)

ROOM AND SRO REVIEW CHECKLIST (to be completed by City staff)

Name of Landlord/

Landlord Representative: __________________________________________________

Name of Organization: ____________________________________________________

Email: _________________________________________________________________

Telephone Number: __________________________ Date of apartment viewing: ________________

Apartment Information

Address: Year of Construction (From DHS Clearance results

document - DOB/Certificate of Occupancy section):

Apartment Number: Floor: Borough: Zip Code:

Total #

rooms:

Total #

bedrooms:

Total # baths:

Total # of units:

Number of people who will live in the apartment:

THIS FORM IS TO BE USED BY DHS STAFF ONLY FOR PERFORMING WALKTHROUGHS FOR ROOMS AND SROS.

UTILITIES (GAS, ELECTRICITY, AND WATER) MUST BE CONNECTED BY THE LANDLORD PRIOR TO THE ROOM OR SRO REVIEW.

1. Interior of Building YES NO N/A

a) Are the interior stairs & halls free of hazards? (e.g. damaged surfaces; peeling, cracked, & loose paint; and loose or missing handrails)

b) Is there excess garbage in the hallways/interior of the building that may cause a health and

safety condition?

c) Do halls and stairwells have a clear path to egress?

d) Do halls and stairwells have sufficient lighting?

e) Is there a working mailbox or mail slot for the tenant?

The mail box/slot must be unique to this unit and not shared with others.

f) Is this unit in a building/house with 3 or more units?

g) If 1f is YES – is there at least one unlocked Fire Exit from the building?

Per NYC fire code, a fire exit is a stairway separated from other interior spaces of a

building by fire-resistant construction so that it provides a protected path of egress out of a

building.

(Turn page)

mailto:[email protected]

http://www1.nyc.gov/site/dss/index.page

DSS-10d (E) 05/10/2019 (page 2 of 7) Department of Social Services

1. Interior of Building (continued) YES NO N/A

h) If 1g is YES - are any of the Fire Exits blocked?

i) If 1f is YES - is there a self-closing mechanism on the apartment entrance door, the

building entrance door, and the Fire Exit doors?

j) If 1f is YES - is there a working bell/buzzer for the apartment?

The bell or buzzer must ring inside the apartment.

2. Hallway and Apartment or House YES NO N/A

a) Is this unit in a building/house with 3 or more units, AND are there children 10 and under in

this household?

b) If 2a is YES - are window guards in place in the hallways and installed with the correct

(one way) screws and L brackets to prevent the window from opening more than 4 inches;

or if there is a casement window hinged at the side or top, is there a chain to prevent the

window from opening more than 4 inches?

If the gap from the top bar of the window guard to the top of the window is less than 4 inches, an L bracket is not required.

Note that window guards should not be installed in fire escape windows.

c) If 2a is YES - are window guards in place in the unit and installed with the correct (one

way) screws and L brackets; or if there is a casement window hinged at the side or top, is

there a chain to prevent the window from opening more than 4 inches?

If the gap from the top bar of the window guard to the top of the window is less than 4 inches, an L bracket is not required.

Note that window guards should not be installed in fire escape windows.

3. Overall Apartment/House YES NO N/A

a) Is the apartment being repaired or under renovation or construction?

If the unit is being repaired or is under construction, it is not suitable for a client.

b) Is there a fire escape?

c) If 3b is YES - are there window gates on the window leading to the fire escape?

(Turn page)


3. Overall Apartment/House (continued) YES NO N/A

d) If 3c is YES - can the window gates be opened from the inside?

For example, the gates must not have padlocks.

e) If 3b is YES – are the window gates on the fire escape window stamped with an FDNY

approval number and can they be opened without the use of a key?

f) If 3b is YES - are there locks on the interior doors of the apartment that have access to that

fire escape window?

g) Do the windows open, close, and lock freely?

You can ask the landlord/landlord representative to do this.

h) Is there a window leading to the outside (basement, first floor, fire escape, porch, or other

outside place that can be reached from the ground)?

i) If 3h is YES – is it lockable from the inside (to protect individuals from invasion)?

j) Are all interior surfaces free of cracked, peeling & loose paint?

k) If 3j is NO - is the date of construction 1978 or earlier?

The date of construction can be found on the Certificate of Occupancy. This date is

provided in the Department of Buildings section of the DHS Clearance document.

l) Is the unit free of evidence of rats, mice, roaches, or other vermin?

m) Is the unit free of any evidence of leaks?

n) Are the floors free of hazards?

For example, no gaps, tripping hazards, or protruding nails.

o) Are there any holes in the walls, floors, or ceilings?

p) Is each room that is used for sleeping at least 80 sq. ft., and does each room include a

window or skylight?

A room of under 80 square feet without a window can be used for another purpose, but not

for sleeping. A room used for sleeping must be both 80 square feet and have a window.

q) Is there a lock on the inside of the apartment entrance door requiring a key to exit the apartment?

No double cylinder locks are permitted.

r) Is there a smoke detector located within 15 feet of the entrance to each room that is used

for sleeping?

s) If 3r is YES - are all of the smoke detectors working?

t) Is there a carbon monoxide detector located within 15 feet of the entrance to each room

that is used for sleeping?

(Turn page)


3. Overall Apartment/House (continued) YES NO N/A

u) If 3t is YES - are all of the carbon monoxide detectors working?

v) Is there a heat source in every room of this unit?

Portable heating units are not permissible.

w) Is the heat source a radiator?

x) If 3w is YES – is there steam coming from the radiator or from the pressure valve, or is

there moisture around the pressure valve?

y) If 3w is YES – is there evidence of leaking on, under, or around the radiator?

z) If 3w is YES - is the radiator missing a knob or valve?

Check the N/A box if you were unable to observe the knob or valve due to the cover

aa) Is this apartment in the basement, cellar, or attic?

ab) Can the unit be accessed without having to go through another unit?

ac)

Does the unit have a porch or balcony?

ad) If 3ac is YES – is it 30 inches or more above the ground?

ae) If 3ad is YES, is a railing present and secure?

af)

Is there a drop ceiling (a secondary ceiling hung beneath the main ceiling)?

ag)

Do you have reason to think that this apartment was illegally subdivided?

ah) Are there locks on the interior doors that have access to a fire escape?

ai) Is there an unlocked Fire Exit/Fire Escape accessible from all areas of the unit?

aj) Are all interior doors hung properly and provide secure privacy?

ak) Are heat, hot water, electricity and gas included?

al) If the inspection occurs between 10/1 and 5/31 it is required for the heat to be working. Take the temperature in at least one room (not the bathroom or kitchen). During the day (6 AM – 10 PM), if the outside temperature falls below 55 degrees Fahrenheit, the inside temperature must be at least 68 degrees Fahrenheit. If the outside temperature is above 55 degrees Fahrenheit, there is no minimum indoor temperature. At night (between 10 PM – 6 AM), the inside temperature must be at least 62 degrees Fahrenheit at all times.

Inside Temperature:

______________

(Fahrenheit)

Outside Temperature:

______________

(Fahrenheit)

(Turn page)


4. Bathroom YES NO N/A

a) Do the sink, tub/standing shower, and showerhead have hot and cold running water?

b) Does the water in the sink, tub/standing shower, and showerhead flow freely?

c) Is the water in the sink, tub/standing shower, and showerhead clean after flushing the

pipes for at least 60 seconds (i.e. no rust)?

d) Is the toilet in proper working order?

e) Is there a vent or an operable window in the bathroom?

You should check for presence of vent airflow/draw.

f) Is the bathroom free of plumbing leaks (including steam leaks)?

g) Is there a bathroom accessible to all occupants of the unit?

5. Kitchen YES NO N/A

a) Does the kitchen sink have hot and cold running water?

b) Is the water in the sink clean after flushing the pipe for at least 60 seconds (i.e. no rust)?

c) Is there a working oven?

d) Is there a working stove?

All burners on the stove must be working.

e) Is there a working refrigerator with rails and shelves adequate to the household’s needs?

f) Is the refrigerator cold?

g) Is there a working freezer?

h) Does the kitchen have cabinets, shelves, or a space to store food?

i) Does the kitchen have a meal preparation area (e.g., counter space)?

j) Is the kitchen free of plumbing leaks (including steam leaks)?

k) Is the stove or oven free of grease build-up?

l) Is there a working vent over the stove or a window in the kitchen?

m) Is there a kitchen accessible to all occupants of the unit?

(Turn page)


6. Electrical YES NO N/A

a) Does each room that will be used for sleeping have either two electrical outlets or one

outlet and one permanent light fixture?

b) Do all of the outlets in the kitchen and bathroom have a reset button

(GFCI Outlet)?

c) Are fixtures and electrical devices secure, with no exposed wires, and do they have plate

covers?

d) Is the apartment free of exposed wires?

Wires that connect to a cable box are not considered exposed wires.

e) Are there any wires located in or located near standing water?

7. Accessibility – Information Gathering Only YES NO N/A

a) Are there any stairs (or steps) between the public sidewalk and the door to the unit?

b) If 7a is YES - is it possible to avoid all of the stairs (or steps) between the public sidewalk

and the door to the unit by, for example, using an alternate tenant-entrance to the building,

or by using an elevator (or lift), and/or ramp?

c) Does the building have an elevator?

d) If 7c is YES - is at least one in working order?

e) What are the widths of the following:

Front entrance of the building: _______________________

Elevator door: _______________________

Entrance to the apartment: _______________________

Bathroom doors (if more than one bathroom, it is only necessary to measure one): _______________________

To comply with the Americans with Disabilities Act, elevator doors must be 36 inches wide and doorways must be 32 inches wide.

(Turn page)


8. Approval YES NO

a) Are there any other issues that would make the apartment unsuitable to rent?

If so, what are they?

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

b) Based on the answers you have provided above, do you approve of this apartment for rent

by this client?

Certification of Completed Walkthrough

I certify that I visited the property located at the address indicated above and that the information in this form has been

answered correctly to the best of my ability.

DHS Staff Name (Print) DHS Staff Signature Date

DSS-10e (E) 05/14/2019 (page 1 of 2)

UNIT WALKTHROUGH OUTCOME

Reason for Review: Apartment Walkthrough Room Walkthrough Apartment Escalation

Building Address: __________________________________________________________________________________

Apartment Number: ___________________ Floor: ____________________ Walkthrough Date: __________________

THE ABOVE UNIT: PASSED FAILED NO ACCESS TO UNIT GIVEN

If applicable, list the reason(s) why the Unit failed. Include the letter of each failed item in its appropriate section below.

1. Interior of Building: ________________________________________________________________________

2. Hallway and Apartment or House: ____________________________________________________________

3. Overall Apartment/House: _____________________________________________________________________

4. Bathroom: _________________________________________________________________________________________________

5. Kitchen: ___________________________________________________________________________________________________

6. Electrical: ________________________________________________________________________________

8. Approval (provide a detailed description for items 8a & 8b, if applicable): ______________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Note: Section 7. Accessibility is not included above because it is intended for information gathering only.

An abbreviated list of each question from the Apartment Review Checklist (DSS-10a) appears on page 2 of this form.

Failed conditions will require an additional walkthrough. Please contact the party checked below when the unit is

ready. DHS HRA Provider

Certification

I certify that I visited the property located at the address indicated above and that the information in this form has been answered correctly to the best of my ability.

Person completing walkthrough (Print) Person completing walkthrough (Signature) Date

Name of your organization (Print)

Landlord/Landlord Representative Name (Print) Landlord/Landlord Representative (Signature)

(Turn page)

DSS-10e (E) 05/14/2019 (page 2 of 2) Department of Social Services Human Resources Administration

Section 1: Interior of building

1a. Stairs and halls not free of hazards 1b. Stairs and halls not free of excess garbage 1c. No clear path to egress 1d. Insufficient lighting 1e. No working mailbox/slot 1g. Fire exit is locked 1h. Fire exit is blocked 1i. No self-closing door 1j. No bell or buzzer

Section 3: Overall Apartment/House (continued)

3ah. Interior doors with fire escape access cannot have locks

3ai. Fire Exit/Fire Escape must be accessible from all areas of the unit

3aj. Interior doors not properly secured 3ak. All utilities must be included in room/SRO rentals 3al. Unit temperature is not adequate

Section 2: Hallway and Apartment/House

2b. No window guards in hallway 2c. No window guards in unit

Section 4: Bathroom

4a. No running hot or cold water 4b. No freely flowing water 4c. Water is not clean or free of rust 4d. Toilet is not working 4e. No vent or operable window 4f. Bathroom has plumbing leaks 4g. Bathroom must be accessible to all occupants of unit

Section 3: Overall Apartment/House

3a. Unit under repair, renovation, or construction 3d. Fire escape window gate(s) cannot be opened from the inside 3e. Window gate(s) has no FDNY stamp 3f. Door to room with fire escape window has lock 3g. Window(s) is not operable 3i. Window to ground is not lockable 3j. Unit has cracked, peeling, or loose paint 3k. Unit was constructed in 1978 or earlier (ESCALATE) 3l. Unit is not free of vermin 3m.Unit is not free of leaks 3n. Floor not free of hazards 3o. Holes in walls, floors, or ceilings 3p. Sleeping rooms are not at least 80 sq ft & do not include window or skylight 3q. Apartment door requires key to exit 3r. Smoke detector is not present or is more than 15 ft from sleeping room entrance 3s. Smoke detector is not working 3t. Carbon monoxide detector is not present or is more than 15 ft from sleeping room entrance 3u. Carbon monoxide detector is not working 3v. Unit does not have heat source in every room 3x. Radiator steam is visible (ESCALATE) 3y. Radiator is leaking (ESCALATE) 3z. Radiator is missing knob or valve (ESCALATE) 3aa. Unit is in basement, cellar, or attic (ESCALATE) 3ab. Unit can only be accessed through another unit 3ae. Porch or balcony has no railing 3af. Unit has dropped ceiling (ESCALATE) 3ag. Unit has potential illegal subdivision (ESCALATE)

Section 5: Kitchen

5a. No running hot or cold water 5b. Water in sink is not clean after running 5c. No working oven 5d. No working stove 5e. Refrigerator rails and shelves are inadequate 5f. Refrigerator is not cold 5g. Freezer is not working 5h. No food storage space 5i. No meal preparation area 5j. Kitchen has plumbing leaks 5k. Stove or oven has grease build-up 5l. No working vent over stove or window in kitchen 5m. Kitchen must be accessible to all occupants of unit

Section 6: Electrical

6a. Sleeping rooms lack two outlets OR one outlet plus one light fixture 6b. Outlets in kitchen and bathroom are not GFCI outlets 6c. Fixtures and electrical devices are not secured or lack plate covers 6d. Unit has exposed wires 6e. Unit has wires in or near standing water

Section 8: Approval

8a. Other issue 8b. Not approved for rent

DSS-10f (E) 05/14/2019 (page 1 of 2)

Attestation of Compliance for

Addressing Potential Lead Based Paint Hazards

Attestation of Compliance for Addressing Potential Lead Based Paint Hazards for Dwelling Units in Pre-1978 Multiple Dwellings and Compliance with Turnover Requirements for Pre-1960 Dwelling Units In Accordance With §27-2056.8 of Article 14 of the Housing Maintenance Code and §11-05 of Title 28 of the Rules of the City of New York Address (Property or Unit):_______________________________________________________________________

State of New York

County of ____________________________________

I, _____________________________________ (PRINT NAME), swear or affirm under penalty of perjury as follows:

1. That I am the (check applicable box)

Owner of the Property or Unit identified above

Registered Managing Agent of the Property or Unit identified above and have proof of such registration

Authorized Agent and have proof of such authorization to act on behalf of the owner of the Property or

Unit identified above

2. That the Property or Unit identified above is currently registered with the Department of Housing Preservation and Development (HPD).

3. That I have examined the potential lead-based paint hazards identified in the DSS Apartment Review Checklist (DSS-10a) or Room and SRO Review Checklist (DSS-10d) form dated ____________ (Deficiency)

and the Deficiency and any underlying condition was remediated on the dates that I have indicated below.

4. That I have read HPD’s Guide to Local Law 1 of 2004 Work Practices, §27-2056.11 of Article 14 of the Housing Maintenance Code, and 28 RCNY §11-06, which are available on HPD’s website, and am aware of the work practices required to correct lead-based paint hazards safely and in accordance with the law.

5. That the following are the names and addresses of my agents or employees who performed the work to remediate the Deficiency.

Date Work Performed

Named of Agent/Employee who performed work

Address of Agent/Employee who performed work

6. That the work to remediate the Deficiency was performed in accordance with all applicable requirements of §27-2056.11 of Article 14 of the Housing Maintenance Code and 28 RCNY §11-06.

7. That the agent or employee listed under paragraph 5 who performed the work to correct the Deficiency had completed all required training applicable to the remediation work undertaken, and that the individual was supervised in accordance with any applicable regulations.

(Turn page)

DSS-10f (E) 05/14/2019 (page 2 of 2)

8. That a lead contaminated dust wipe clearance test was performed by an independent, certified inspector, the clearance tests were analyzed by a laboratory certified in the New York State Environmental Laboratory Approval Program, and the results of the clearance tests were in compliance with the lead contaminated dust levels required for clearance. I have maintained a copy of the lead contaminated dust wipe clearance test and agree to provide the results to DSS upon request.

9. If the subject building was constructed prior to January 1, 1960, that I have complied with all provisions concerning work to be performed using safe work practices in dwelling units at turnover pursuant to § 27-2056.8 of Article 14 of the Housing Maintenance Code and 28 RCNY §11-05, and that pursuant to §27-2056.4, I will deliver all required pamphlets, notices, and disclosures regarding occupancy of a child under age six, lead-based paint hazards, and compliance with the turnover requirements to the occupant.

_______________________________________________ ____________________________ Signature Date

DSS-14 (E) 05/13/2019

Special Supplemental Assistance Fund Claim Request Form

Instructions: Landlords can claim up to $3,000 dollars in expenses that occurred during the duration of the tenancy (CityFHEPS, SEPS, LINC, and CITYFEPS rental assistance program only) provided that the expenses cannot already be covered by other programs such as the security deposit or emergency arrears. Please submit along with this claim form:

• Proof of ownership (of premises); and

• Documentation of unpaid rent (e.g., court judgment or stipulation, landlord breakdown, etc.) or documentation to verify the damage(s) to the apartment and the cost of repairs (e.g., photographs, estimates, receipts for repairs, etc.)

A. PROPERTY INFORMATION

Landlord Name:

Tenant Name: Lease Start Date:

Tenant Address:

B. AMOUNT REQUESTED AND TYPE OF CLAIM REQUEST

Total Amount Requested: Date Submitted:

Check Made Payable To:

Mailing Address:

Reason for Claim (complete the following):

Tenant defaulted on payment of rent for _________ months/year (provide court

judgment, stipulation, landlord breakdown, etc.

Tenant caused damages to the apartment.

C. AFFIRMATION

I ______________________________, hereby swear/affirm, under penalty of perjury, that the information I have given above is true and complete. By signing below, I am agreeing to provide any necessary documents requested by HRA beyond those that have been included in this claims request.

_______________________________ _________________________________________ _______________ Landlord: Print Name Signature Date

Subscribed and sworn to/affirmed before me

this _______ day of ___________, 20______.

Notary’s Signature ______________________________________

Notary Seal:

Send Claim to: Email: [email protected] Fax: 917 639-0366 Mail: Rental Assistance Program Unit, 150 Greenwich Street, 36

th Floor, New York, NY 10007

AGENCY USE ONLY

Request Outcome:

Total Amount Approved:

Tenant Name: Case Number:

Submitted by: Date:

Approved by: Date:

mailto:[email protected]

HRA-145 (E) 06/06/2019

Unit Hold Incentive VoucherThe New York City Human Resources Administration (“HRA”) will provide an additional check for the equivalent of one month’s rent (in the amount listed below) as an incentive for holding the apartment while HRA completes the approval process. This voucher must be submitted as part of a rental assistance housing packet and the incentive check will be provided along with all other initial rent and bonus payments.Approval of the packet is conditioned on, among other things:

The tenant continuing to be otherwise eligible for the rental assistance program;The apartment passing any applicable inspection or safety and habitability assessment;The landlord submitting all applicable rental documents for HRA approval; andHRA confirming that it is not already making payments for this apartment or unit on behalf of anyone who is no longer residing there.

This voucher is available to landlords renting apartments to CityFHEPS and HRA HOME TBRA clients and FHEPS clients moving out of a DSS shelter. It may also be available in other limited circumstances. If the tenant ultimately does not move into the apartment following lease signing, the incentive must be refunded (call 929-221-0043).

A. Landlord or Management Company Information

Name Phone Address City State Zip Code Check One: Landlord ManagementB. Rental Unit

Address Apartment # Monthly Rent

C. Tenant (only one Household may be selected per apartment)

Name Rental Assistance Type

I certify that I own or manage the above-named rental unit and, that the unit is currently vacant. I agree not to lease the unit to any other third-party while the application is being processed.By signing below, I understand that nothing in this document creates a legally enforceable agreement or guarantee by HRA.

Landlord/Authorized Agent’s Name

Landlord/Authorized Agent’s Signature Date

HRA-146m (E) 06/06/2019

FHEPS A DEMOGRAPHIC SHEET


Client’s Name: _______________________________________________________________

Social Security #: __________________________________

Agency Name: _____________________________________ CA Case #: ______________

Staff Contact: _________________________ Staff Phone #: __________________________

Staff e-Mail: _________________________________________________________________

For Clients in Shelter (if applicable):

Facility Code: __________________________ CARES Case #: ______________________

Program Administrator: ___________________ Program Analyst: _____________________


HRA-146a FHEPS Application

HRA-146j or HRA-146k Potential Eligibility for FHEPS (aka “Shopping Letter”)

W-137a Request for Emergency Assistance

W-147n Security Voucher (if requested)

HRA-146p Domestic Violence Action Form (if applicable) Proof of residency in the apartment at the time of eviction (if applicable)

Proof of “eviction”: HPOP Print Out. Court Documentation, etc.

Last 30 days of Pay Stubs or Other Proof of Income (for everyone in the household over 18)

Lease or Agreement for 12 months

To stay only ─ If arrears, Landlord breakdown of arrears

To move only ─ Landlord Proof of Ownership

For Clients in Shelter, did you include:



Shelter Residence Letter

For Clients in Shelter, if Broker and/or Landlord incentives apply, did you include the following?

Landlord W9 (for landlord bonus)



HRA-121 Broker’s Request for Advance Fee Payment by Check (if broker fee)

W-147m Landlord/Managing Agent’s Statement (if broker fee)

Comments:

HRA-146n (E) 06/06/2019 (page 1 of 2)

FHEPS B DEMOGRAPHIC SHEET


Client’s Name: _______________________________________________________________

Social Security #: __________________________________

Agency Name: _____________________________________ CA Case #: ______________

Staff Contact: _________________________ Staff Phone #: __________________________

Staff Email: _________________________________________________________________

For Clients in Shelter (if applicable):

Facility Code: __________________________ CARES Case #: ______________________

Program Administrator: ___________________ Program Analyst: _____________________


HRA-146a FHEPS Application

HRA-146j or HRA-146k Potential Eligibility for FHEPS (aka “Shopping Letter”)

W-137a Request for Emergency Assistance

Lease or Agreement for 12 months

Last 30 days of Pay Stubs or Other Proof of Income (for everyone in the household over 18)

W-147n Security Voucher (if requested)

To stay only – If arrears, Landlord breakdown of arrears

To move only ─ Landlord Proof of Ownership


DSS-10a Apartment Review Checklist (if applicable)

Shelter Residence Letter (if applicable)

Verification of FHEPS B eligibility (for applicants in the community)

For Clients in Shelter, if Broker and/or Landlord incentives apply, did you include the following?

Landlord W9 (for landlord bonus)



HRA-121 Broker’s Request for Advance Fee Payment by Check (if broker fee)

W-147m Landlord/Managing Agent’s Statement (if broker fee)

Comments:

HRA-146n (E) 06/06/2019 (page 2 of 2) Department of Social Services Human Resources Administration

(Turn Page)


Name (print) Title


Signature Date