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Cityfheps Verification of Eligibility: 1. Referral Source

This document is a verification form for eligibility for CityFHEPS, a rental assistance program. It collects information about the applicant's referral source, income level, eligibility criteria, and risk of homelessness. The eligibility criteria section lists six qualifying categories including veteran status, recent eviction, referral from other programs, enrollment in other programs, approved transfer requests, or conversion from other rental assistance programs. Program staff must sign off to verify the applicant's risk of homelessness without the CityFHEPS assistance.

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499 views

Cityfheps Verification of Eligibility: 1. Referral Source

This document is a verification form for eligibility for CityFHEPS, a rental assistance program. It collects information about the applicant's referral source, income level, eligibility criteria, and risk of homelessness. The eligibility criteria section lists six qualifying categories including veteran status, recent eviction, referral from other programs, enrollment in other programs, approved transfer requests, or conversion from other rental assistance programs. Program staff must sign off to verify the applicant's risk of homelessness without the CityFHEPS assistance.

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We take content rights seriously. If you suspect this is your content, claim it here.
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DSS-8e (E) 05/19/2021 (page 1 of 2)

CityFHEPS Verification of Eligibility

Applicant Name: ____________________________________________________________________________

1. Referral Source
 Homebase  HRA APS  ACS  DYCD

2. Income
 New Cases - Household income is at or below 200% of the Federal Poverty Guidelines:  Yes  No
 Transfer cases - Household income is at or below 250% of the Federal Poverty
Guidelines:  Yes  No

3. Eligibility Criteria (must check one of the following six categories)

1. Has any household member served in the United States Armed Forces (veteran)?  Yes  No
If Yes, name of veteran: _____________________________________

2. Has any household member faced an eviction or been evicted in the past year?  Yes  No
If “Yes,” the household must also meet at least one of the criteria below:
a. Is any household member in receipt of Adult Protective Services?  Yes  No
b. Does the household live in a rent-controlled apartment and seek to use rental  Yes  No
assistance to preserve that apartment?

c. Has any household member previously resided in a DHS shelter?  Yes  No


3. Was the household referred by a CityFHEPS qualifying program?  Yes  No
(select the program below)
 DHS Intake (diversion referral form or PCS confirmation email)
 Staten Island Homebase Pilot (referring CAMBA address must be Bay Street)
 NYC Department of Correction Pilot (CARES screen shot showing pilot indicator)
 NHPO (diversion referral form or PCS confirmation email)
 HPD Housing Lottery (HPD letter and CARES shelter history print out)
 Three-Quarter Housing Task Force (HRA Certification Letter [DSS-7b])
 NYC ACS (ACS Certification Letter)
 NYC DYCD (DYCD Certification Letter)
Note: The documentation identified in the parenthesis for each program must be included
in the submitted packet.
4.  PATHWAY Home or LINC VI household
5.  Approved Good Cause transfer request (PCS confirmation email)
6.  Approved Update/Conversion from _________________________________________________
(former rental assistance supplement program)

(Turn Page)
DSS-8e (E) 05/19/2021 (page 2 of 2) Department of Social Services
Human Resources Administration

4. Risk Assessment
Housing Options
Assess the applicant’s housing options, including alternative housing assistance as well as support networks such
as family, friends, faith-based or other social networks.

 Risk of Homelessness (Veterans and CityFHEPS qualifying program referrals only)


I certify that this applicant has been assessed and determined to be at risk of shelter entry but for the assistance
of the CityFHEPS program.

5. Program Staff Signature

Program Staff Signature: _________________________________________ Date:_______________________

Program Staff Name: ____________________________________________

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