CSP#_____________________________

Unified Supportive Housing System (USHS)

Prospective Applicant File Checklist
Use the following checklist to ensure that all necessary documentation has been included before
submission. The contents of this file are valid for 180 days from Prospective Applicant signature
date.

 Release of Information (ROI)

 Demographics Form
 Certification of Disabling Condition (provide one of the following):

 Written verification from a professional who is licensed by the state to diagnose and
treat that condition, stating that the disability is expected to be long-continuing or of
indefinite duration and that the disability substantially impedes the individual’s ability to
live independently. (Certification Of Disability [COD])
 Written verification from the Social Security Administration (SSA).
 Copy of a disability check from SSA or the U.S. Department of Veteran Affairs.

 Income Verification (Documentation of Income or Zero Income Statement)

 Verification of Identity and Citizenship for every member of the household. (Legible and clear
copies only):

 Social Security card or verification of SSN printout from Social Security Administration.
 Original birth certificate or letter/form requesting birth certificate.
 Current State of Ohio issued photo ID or Driver’s License with Franklin County address.
[Not required for minors under the age of 18]
 Name on Social Security documentation, birth certificate and photo ID match or
verification of legal name change included

 Documentation of Homelessness (CSP Printout and/or Street Homeless Verification Form or

Homeless Verification for client residing at CHOICES)
 Unit Specific Documentation for Veteran’s and Family Units (If applicable)

By signing below I assert that I believe this applicant can benefit from Permanent Supportive
Housing due to a long history of homelessness and the presence of a disabling condition that
impedes independent living. I further assert that I have personally examined all documentation.
To my knowledge all information contained herein, is accurate, truthful and complete.

Provider
Agency Rep. Printed Name Signature Date

\\csbsrv01\csb\Rebuilding Lives Plan\Active Projects\Unified Supportive Housing System\Forms\USHS Forms\2018\USHS PA File_rev_04042018.docx

 CSP#________________

Unified Supportive Housing System (USHS)

Authorization for Release of Information

Prospective Applicant Name: _____________________________________________________

The Unified Supportive Housing System (USHS) Prospective Applicant File collects information,
which helps to determine preliminary eligibility for housing and community supports to assist with
housing stability. USHS also requires additional information to be provided by other government
agencies and service providers. In order for USHS to collect the information and process the form,
your consent to release information is required.
I. USHS understands that information about you, your health, employment/income, and housing
history are personal, and we are committed to protecting the privacy of that information. Because
of this commitment, we must obtain your written authorization before using or disclosing your
protected health and personal information for the purposes described below. This form provides
that authorization and helps us make sure that you are properly informed of how this information
will be used or disclosed.

II. Purpose: Provider Agency (name of agency assisting Prospective Applicant to complete this form)
_________________________________________, Unified Supportive Housing System, Alcohol
Drug and Mental Health Board (ADAMH), Community Shelter Board (CSB), Franklin County
Children Services (FCCS), and the following housing providers: Alvis, Equitas, Community Housing
Network (CHN), Maryhaven, National Church Residences (N^^), Volunteers of America of Greater
Ohio (VOAGO), YMCA, and YWCA may use this authorization and the information obtained with it,
to collect and share with agencies named above, the information about my household members
and me outlined in Part III below. The purpose of collecting and sharing information is to
determine preliminary eligibility for supportive housing.

III. Authorization: For a period of six months from the date of my signature below, I authorize the
above named organizations to obtain information about me or my family that is pertinent to my
USHS file.

IV. Information Covered-Inquiries may be made about: Physical and Mental Health records,
Substance Abuse Treatment records, Child Care Expenses, Handicapped Assistance Expenses,
Credit History, Identity and Marital Status, Criminal Activity, Medical Expenses, Family
Composition, Social Security Numbers, Federal/State/Tribal/Local Benefits, Residences and
Rental History, Homeless History, History with FCCS, Columbus Metropolitan Housing Authority
(CMHA), ADAMH (current and previous service utilization and linkage with ADAMH Provider
Agencies), CSB programs, and Employment/Income/ Pensions/Assets.

V. Individuals/Organizations that may Release Information: Any individual or organization including

any governmental organization may be asked to release information. For example, information
may be requested from: ADAMH, CMHA, CSB, FCCS, housing providers mentioned in Section I
above, Banks and Financial Institutions, Utility Companies, Landlords, Employers – Present and
Past, Courts, U.S. Dept. of Veterans Affairs, Welfare Agencies, Law Enforcement Agencies, Credit
Bureaus, Schools or Colleges, U.S. Social Security Administration, Providers of: Alimony,
Substance Abuse services, Case Management services, Child Care, Child Support, Credit,
Handicapped Assistance, Medical Care (including mental health services), Pensions/Annuities,
Emergency Shelters and Housing Services.

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VI. Minor Children: If I am a custodial parent of a minor child, I also give my authorization for the
following children:

First Name Middle Name Last Name Date of Birth

VII. Revocation: I understand that I have the right to revoke this authorization at any time by notifying
the USHS Project Manager in writing at: 111 Liberty St., Suite 150, Columbus, OH 43215. I
understand that the revocation is only effective after it is received and logged by USHS. I
understand that any use or disclosure made prior to the revocation of this authorization will not be
affected by the revocation and the revocation will not apply to disclosures made in reliance on the
authorization. I understand that after the information is disclosed, federal or state law might not
protect it, and the recipient might re-disclose it.

VIII. Database Matching Notice /Consent: I agree that the above named organizations using my
information can conduct computer matching with other government agencies including Federal,
State, Tribal or Local agencies. The government agencies include: Ohio Departments of Mental
Health, Alcohol and Drug Addiction Services, Job and Family Services, U.S. Office of Personnel
Management, U.S. Social Security Administration, State Employment Security Agencies, and State
Welfare and Food Stamp Agencies.

IX. I also agree that the above named organizations may enter personal information on members of
my household and me and may research my information in Columbus ServicePoint (CSP), the
database which is used by agencies providing shelter and housing-related services in Franklin
County, MACSIS, the database which is used by agencies in the Mental Health system and
SHARES, the database which is used by agencies funded by the Alcohol, Drug and Mental Health
Board of Franklin County.

X. Conditions: I agree that photocopies of this authorization may be used for the purposes stated
above. If I do not sign this authorization or if I sign this authorization and later revoke it, I

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understand that my USHS file will not be processed. This release of information is valid for six
months from the date of signing.

______________________________________________ __________________
Signature, Head of Household Date

For USHS Use Only

Rcvd By______________________________________ Date of Revocation: __________

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 Homeless  Non-Homeless ADAMH Client Non-Homeless VHA Eligible VET N^^ MED/Choice
Unified Supportive Housing System (USHS)
Prospective Applicant Demographics
Name:

Alias/Maiden Name:

Date of Birth:

Social Security
Number:

Phone Number:

Provider Name:

Provider Email: Provider Phone:

Race (Voluntary):
 American Indian/Alaskan  Native Hawaiian/Other
Native Pacific Islander
 Asian  White
 Black/African American Other___________________

Ethnicity (Voluntary):
 Hispanic/Latino  Non-Hispanic/Latino

Are You a US Citizen or Legal US Resident?

 Yes  No

Gender Identity:
 Male  Trans Female (MTF or Male  Gender Non-Conforming
 Female to Female)  Other
 Trans Male (FTM or Female _______________________
to Male)

Are You Currently Pregnant? If yes, which trimester?

 Yes  No  N/A  1st (1-3 months)
 2nd (4-6 months)
 3rd (7-9 months)

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Are You a Fulltime Student?

 Yes  No

Do You Have a Legal Guardian?

 Yes  No

Do You Currently Have a Payee?

 Yes  No

Are you Able to Turn on Utilities (i.e. gas, water, electricity) in Your Name?
 Yes  No

Do You Owe Any Money to a Utility Company?

 Yes  No
If Yes, which utlity(ies):_______________________________________________________

Do You or a Member of Your If yes, please check yes and below which accommodation(s) you
Family Require Special need:
Accommodations?
 Yes  No  Wheelchair accessible  Hearing disability
 No steps  Grab bars and handrails
 Few steps  Modification for vision or
 Handicap accessible parking hearing impairment

Total Monthly Income: $

Do You Receive Any of the Following: (Check all that Apply)

 Alimony  Private disability insurance  Unemployment Insurance
 Child support  Retirement income from  VA Non-Service Connected
 Earned income Social Security Disability Pension
 General Assistance  SSDI  VA Service Connected
 Pension or retirement  SSI Disability Compensation
income from another job  TANF  Workers Compensation

Do You Have Any of the Following? (Check all that Apply)

 Checking account  Retirement  TANF Child Care Services
 Direct Express Account  Savings account  TANF Transportation Services
 Life insurance  SNAP (Food Stamps)  WIC

Health Insurance Type: (Check all that Apply)

 MEDICAID  VA Medical Services  Private Pay Health Insurance
 MEDICARE  Employer-Provided  State Health Insurance for
 State Children’s Health Insurance Adults
Insurance Program (SCHIP)  Health Insurance obtained  Indian Health Services
through COBRA  Not Covered

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Do You Have one (1) or More If yes, what type of animal is it? Is your pet a service or
Pets? therapeutic animal?
 Yes  No  Cat  Dog  Other  Yes  No

Are You Currently Linked to a  Yes*  No *If yes, please give that
Mental Health Provider? Agency’s Name Below:

___________________________
Mental Health Case
Manager Name (If
Applicable)
Are You a person Who Served at Least One Day of Active Military, Naval, or Air Service and Who
was Discharged or Released Under Conditions Other Than Dishonorable?
 Yes  No

Prospective Applicant’s Current Living Arrangement:

HOMELESS SITUATION INSTITUTIONAL SETTING TRANSITIONAL AND
 Place not meant for  Foster care home or foster PERMANENT HOUSING
habitation care group home SITUATION
 Emergency shelter  Hospital or other residential  Residence owned
(including, CHOICES for non-psychiatric medical  Rental without subsidy
Victims of Domestic facilities  Permanent housing (other
Violence)  Jail, prison or juvenile than RRH) for formerly
detention facility homeless persons
 Long-term care facility or  Rental by client with other
nursing home ongoing housing subsidy
 Psychiatric hospital or other (including RRH)
psychiatric facility  Transitional housing for
 Substance abuse treatment homeless persons (including
facility or detox center homeless youth)

Will There be Another Adult  Yes*  No *If yes, please Give that
Residing with You in the Person’s Name Below:
Household?
___________________________
Do Currently Have Legal Custody of Any Minor Children?
 Yes*  No *If so, please ensure that minor children are on the Release of
Information Form.

*Please Note: All prospective applicants are given two (2) opportunities to accept a housing unit
that is not substandard housing for any reason. Prospective applicants are expected to
tour unit/housing property prior to refusal. Refusal to accept a safe, decent, affordable
housing option twice will result in the individual being ineligible for Housing through Unified
Supportive Housing System (USHS) for one (1) calendar year.

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I understand that open criminal cases or active warrants may delay processing of my file for
housing access. Past criminal background will be reviewed and may affect my eligibility for
housing within the USHS, based on restrictions in place at different housing sites. These
restrictions are based on federal, state or local requirements that the USHS is not in
control of.

I understand that my completion of this form does not guarantee housing in the Unified
Supportive Housing System. I further understand that my case worker should continue to
assist me in finding an appropriate living situation. I certify, under penalty of law, that the
above information provided by me on this form is true and complete to the best of my
knowledge and ability.

_______________________________________________ ____________________________
Signature, Prospective Applicant Date
__________________________________________________________________________________
Provider Agency Use Only
[Not for Diagnostic Purposes]

The Prospective Applicant has a “disabling condition” meaning they have:

 A physical, mental, or emotional impairment, including an impairment caused by alcohol or
drug abuse, post-traumatic stress disorder, or brain injury that:
1) Is expected to be long-continuing or of indefinite duration;
2) Substantially impedes the individual's ability to live independently; and
3) Could be improved by the provision of more suitable housing conditions.
 A developmental disability, as defined in section 102 of the Developmental Disabilities
Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15002); or
 The disease of acquired immunodeficiency syndrome (AIDS) or any condition arising from
the etiologic agency for acquired immunodeficiency syndrome (HIV).

(Check All That Apply to Ensure Appropriate Placement)

Mental or Emotional Impairment Physical Impairment

 Yes  No  Yes  No

Alcohol or Drug Abuse Post-traumatic Stress Disorder

 Yes  No  Yes  No

Brain Injury Developmental Disability

 Yes  No  Yes  No

Acquired immunodeficiency syndrome (AIDS) or any condition arising from the etiologic agency for
acquired immunodeficiency syndrome (HIV)
 Yes  No

Signature, Provider Agency Representative Date

Printed Name Provider Agency Name

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Certification of Disability

An individual with a “disabling condition” has one or more of the following:

 A physical, mental, or emotional impairment, including an impairment caused by alcohol or

drug abuse, post-traumatic stress disorder, or brain injury that:
1) Is expected to be long-continuing or of indefinite duration;
2) Substantially impedes the individual's ability to live independently; and
3) Could be improved by the provision of more suitable housing conditions.

 A developmental disability, as defined in section 102 of the Developmental Disabilities

Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15002); or

 The disease of acquired immunodeficiency syndrome (AIDS) or any condition arising from
the etiologic agency for acquired immunodeficiency syndrome (HIV).

I have read the above definition of “disabling condition” and I hereby certify that
____________________________________________________ has a disabling condition.

I further certify that I am a professional licensed by the state to diagnose AND treat the disability
and that the disability is expected to be long-continuing or of indefinite duration and substantially
impedes the individual’s ability to live independently.

 Physician  LPCC
 CNP  PCC
 CNS  LICDC
Authorized Signature Date  LISW

Printed Name

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Unified Supportive Housing System (USHS)

Declaration of Zero Income

I _____________________________________, understand that the information provided on this

form will be used to determine income eligibility. I have read the clarification for what is
considered income* and hereby certify that I am currently receiving no income from any source.

I certify that this statement is true to the best of my knowledge and understand providing false,
misleading or incorrect information may result in ineligibility for Housing Provider units in the
Unified Supportive Housing System (USHS).

_______________________________ ___________________
Prospective Applicant Signature ** Date

_______________________________ ___________________
Provider Agency Representative Date

*Income: Wages from job, self-employment, Social Security, Social Security Income (SSI),
Pension/Veteran’s Administration (Military Pay), TANF/Ohio Works First (Public Assistance),
Unemployment Benefits, Workers Compensation, Educational Financial Assistance (Financial
Aid), Court-Ordered Child Support Payments Received, Informal Child Support Payments Received
and Alimony.

**Document is valid for thirty (30) days from the signature date. Upon referral Housing Provider
will ask for updated income verification.

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Please include: Income documentation if client did not

complete the zero income statement.

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Please include for every household member:

(1) Social security card or SSN printout

2) Birth Certificate or copy of request for Birth Certificate;
Passport is also acceptable.
(3) Current State of Ohio issued photo id or Driver’s
License with Franklin County, Oh address (Not required for
minors under the age of 18)

*Please verify that all names match across

documentation, if not please provide documentation of
legal name change.
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Please Include: Documentation of Homelessness:

(1) Columbus ServicePoint (CSP) Entry/Exit Record and/or
(2) Verification of Street Homelessness Form, or
(3) Letter from Choices for Victims of Domestic Violence.

Please Include: Documentation of Institutional Stay of Less

Than 90 Days (if homeless immediately prior to entry) if
attempting to count stay towards homeless time

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For Prospective Applicants with minor children please

include:
(1) Copy of the JFS “Proof of Eligibility” Printout,
(2) Court Documentation of Custody, or
(3) Custody/Guardianship documentation from Franklin
County Children Services

For VHA eligible Prospective Applicants please include:

Documentation of Veteran status (DD-214/215, NGB
22/22A or VA ID).

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