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Cityfheps Packet Cover Sheet - Shelter: Dss-8H (E) 12/20/2022 (Page 1 of 2)

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780 views

Cityfheps Packet Cover Sheet - Shelter: Dss-8H (E) 12/20/2022 (Page 1 of 2)

Uploaded by

simonastarr123
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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DSS-8h (E) 12/20/2022 (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”)  Proof of Apartment/Room Preclearance
 DSS-7a or DSS-7c (“Household Share Letter”)  DSS-10a Apartment Review Checklist

 Proof of last 30 days of Income  Deed/Proof of Ownership


(for everyone in the household 18+)  DSS-8f or DSS-8g (“Landlord Information
Form")
 W-137A Request for Emergency Assistance
 DSS-7p Program Participant Agreement  Signed by managing agent or other
authorized representative? If checked,
 Lease or Rental Agreement for 12 months
 Proof of HPD Registration or
 Shelter Residency Letter Authorization
 DSS-8b Tenant Contact Information  W-147N Security Voucher
 Landlord W9  DSS-8q Landlord Utility Information

Check the rental type and associated forms included. Also check which landlord incentives apply, if any:
 Room Rental?  Apartment/SRO Rental?
 DSS-8d Room Allocation Form  HRA-145 Unit Hold Incentive Voucher
 Landlord Bonus (availability based on
zip code)
 CityFHEPS Rental Assistance
Supplement
 1 month OR  3 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) 12/20/2022 (page 2 of 2) Department of Social Services
Human Resources Administration

SUPERVISORY REVIEW (Director of Social Services or higher)

Name Title

Email Address Telephone Number

Signature Date

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