Section 1

HSDF Adult Services Eligibility Form

Self Sufficiency Matrix

ORS Intake Form

Proof of US Citizenship
(copy Driver’s License, Birth Certificate and Social Security card for all members
in the household)

Determination of Need
(caseworker determines the reason for need)

Affordability determined by Monthly Living Expenses

Staff Certification of Eligibility for Assistance

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

------------------------------------~---------- ---

HUMAN SERVICES DEVELOPMENT FUND

ADULT SERVICES ELIGIBILITY FORM
1. NAME OF APPLICANT (Last, First, Middle Initial) TELEPHONE NUMBER

Zeth, Lori 814-660-9895

ADDRESS (Street, Road, Avenue - City or Town, State) ZIP CODE COUNTY

223 Cherry St, Roaring Springs, PA 16673 Bedford

.i. FAM1L v.·.••~911.1~0$Jt10NC!ill11~ jp~c~.be16.wns
LINE> \·NAME %(i..1$t)tii$i; ihitl~J).i
NO, ii (1!1~14~6 :A:pp!J#~ijt) ........ .
1 Zeth, Lori 11 01 83 F

1. APPLICANT MEETS AGE REQUIREMENTS? □ YES □ NO DYES ONo DYES DNo

2. IS APPLICANT A COUNTY RESIDENT? □ YES □ NO □ YES □ NO □ YES □ NO

RECIP. NO.: RECIP. NO.: RECIP. NO.:
3-a. INCOME: Does applicant possess an
ACCESS (Medical Assistance) Card? □ YES 1--C-A-R□-,s~su_E_N_0_.,----1 □ YES 1--C-A-R□-,s-su_E_N_0_.,----1 □ YES 1--C-A-RD-lS-SU_E_N_0_.,----1

Document Card Nos. & Call EVS to

Confirm Eligibility: 1-800-766-5387. □ NO □ATE: □ NO DATE: □ NO □ ATE:

MO. DAY YR. MO. DAY YR. MO. DAY YR.

Specify: Verification Date You Entered &
EVS Responses of Birth date (BO). Gender (Gl. t-:8c-c0-.. - - ~ - - . - , - - - - ' - - - - 1 - ~ - - ~ - - , - , - - - - ' ~ - - - + - - - - - - ' ~ - - , - ~ - - - - - 1
0 00 0 80 0
& MA Codes: Health Care Benefits (HCB), ' D M D F ' ' D M D F ' ' D M D F
Category (Cl, & Program Status (PS). Hca: CAT: PS: HCB: CAT: PS: HCB: CAT: PS:

Eligible for HSDF Service per EVS?

(If no, use 3b.) LJYES LJNO LJYES LJNO LJYES LJNO
IF NO - COMPLETE THE FOLLOWING APPLICANT MEETS

••••··••··••·••••<••··~q·&t~i+Y•··•·•t·.•·
GA9SSi AMQPfll!
No Income 0

0 1
INCOME ELIGIBLE?

□ YES □ NO

TOTAL·· FAMILY SIZE

, INCOME ELIGIBLE?

□ YES □ NO

C .,_.~~~----,-,---=----------+------•-
TOTAL. FAMILV MONTHLY.·G~OSS INC'.;.OME ►
---~
TOTAL FAMILY SIZE ►
--
LESS MEDiCAL . EXPENSE ~XCLUSION (Se~ §~05(.).731 ► 1---------1
INCOME ELIGIBLE?

TOTALJAMl~Y .ADJ. MONTHLY GROSil!'ftOME ► □ YES □ No

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f
. 4.
DOES THE APPLICANT MEET ALL
APPLICABLE NEED CRITERIA? □ vES □ No DvEs ONo DvEs DNo
l------~C1-------1
NEED
·•·•.··FOR·•
IS THE APPLICANT'S SERVICE NEED
DOCUMENTED IN THE CLIENT RECORD? □ vES □ No □ vES □ No □ vES □ No
SERVI CE ~W_r_i_t_t_e_n_d-oc_u_m_e_n_t_a_t_1_·o-n-n-1u_s_t_b_e_m_a_i""n-'-t..._a.1...i-ne_d_1_·n_t_h_e_C_l_i_e_n_t-'-R-'-e_c_..o_r_d_t_o_e_s_t_a_b_l_f_s_h_th'--'a~t_._t_h_e_c_l_f_e_n_t_n_e_e_d-ts
the service, and that al I appl tcable criteria, categories or condftfons of need are met.

I HEREBY CERTIFY THAT, TO THE BEST OF MY KNOWLEDGE, THE INFORMATION CONTAINED HEREIN IS TRUE, CORRECT
AND COMPLETE. I AGREE TO REPORT ANY CHANGES IN CIRCUMSTANCES IMMEDIATELY TO THIS SERVICE PROVIDER. I
UNDERSTAND THAT DOCUMENTATION OF ALL ELIGIBILITY FACTORS MAY BE REQUIRED TO DETERMINE ELIGIBILITY
CORRECTLY OR FOR AUDITING PURPOSES. I UNDERSTAND THAT IF HAVE A RIGHT TO REQUEST A DEPARTMENT OF
PUBLIC WELFARE FAIR HEARING. THIS AFFIRMATION. STATEMENT COVERS ALL ATTACHMENTS REQUIRED FOR THE
DETERMINATION OF ELIGIBILITY UNDER THE HUMAN SERVICES DEVELOPMENT FUND.
SIGNATURE OF APPLICANT OR PERSON ACTING ON APPLICANTS SIGNATURE OF INTERVIEWER
BEHALF

Mar 09 2021 Mar 09 2021

SIGNATURE DATE• SIGNATURE DATE•

SIGNATURE DATE• SIGNATURE DATE•

SIGNATURE DATE• SIGNATURE DATE•

REASON FOR SIGNATURE IF OTHER THAN APPLICANT. PROVIDER AGENCY NAME

ADDRESS

•Date Signed - must be entered or application is not valid.

DATE DATE
□ ELIGIBLE □ INELIGIBLE

► □ ELIGIBLE □ INELIGIBLE Lt~z~~~~~f ►-

DATE DATE
.·.e....· •· ~~~l8ibt" t
ELIGIBILITY (EXPLAIN)

.· ►
.□ ELIGIBLE □ ► REDETERMINA~ ►
DATE DATE
ELIGIBILJrY.i
C . STATUS INELIGIBLE ·.·.APPtlCANT
NOTIFIED .
· . _TION DUE ·.·
ELIGIBILITY (EXPLAIN)

045778 eversign Document Hash: ad28d070a36f48db9eec14d06857c90f PW 1311 ' - 4/96 .

CSBG INTAKE PACKET

ARIZONA MATRIX
PARTICIPANT NAME DOB ASSESSMENT DATE
INITIAL
Lori Zeth 11/01/83 03/09/21 INTERIM
EXIT

PROGRAM NAME HMIS ID

SC-COC ZETL0

Center for Community Action 195 Drive In Ln Everett, PA 15537 814-623-9129

CCA is an equal opportunity employer and provider.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CSBG INTAKE PACKET

DOMAIN 1 2 3 4 5 SCORE PARTICIPANT GOAL?

In transitional, temporary
or substandard housing;
In stable housing that is Household is in safe,
Homeless or threatened with and/or current Household is safe, adequate,
HOUSING
eviction. rent/mortgage payment is
safe but only marginally adequate subsidized
unsubsidized housing
1 5
adequate. housing.
unaffordable (over 30% of
income).
Temporary, part-time or Employed full time; Maintains permanent
Employed full time with 1 4
EMPLOYMENT No job seasonal; inadequate pay, inadequate pay; few or no employment with adequate
adequate pay and benefits.
no benefits. benefits. income and benefits.

Inadequate income and/or Can meet basic needs with Can meet basic needs and Income is enough, well
INCOME No income spontaneous or subsidy; appropriate manage debt without managed; has discretionary 1 4
inappropriate spending. spending. assistance. income and is able to save.
No food or means to prepare
Can meet basic food needs
it. Relies to a significant Household is on food Can meet basic food needs Can choose to purchase any 2 4
FOOD but requires occasional
degree on other sources of stamps. without assistance. food household desires.
assistance.
free or low-cost food.
Childcare is unreliable or
Needs childcare, but none is unaffordable, inadequate Affordable subsidized Reliable, affordable
Able to select quality n/a n/a
CHILD CARE available/accessible and/or supervision is a problem childcare is available but childcare is available, no
childcare of choice.
child is not eligible. for childcare that is limited. need for subsidies.
available.
Enrolled in school, but one
One or more school-aged One or more school-aged Enrolled in school and All school-aged children
or more children only n/a n/a
CHILDREN’S EDUCATION children enrolled in school, children enrolled in school, attending classes most of enrolled and attending on a
occasionally attending
but not attending classes. but not attending classes. the time. regular basis.
classes.
Needs additional
Enrolled in literacy and/or
education/training to
Literacy problems and/or no GED program and/or has Has completed
improve employment
high school diploma/GED are enough command of Has high school education/training needed
ADULT EDUCATION situation and/or to resolve 5 5
serious barriers to English to where language diploma/GED. to become employable. No
literacy problems to where
employment. is not a barrier to literacy problems.
they can function effectively
employment.
in society.
No medical coverage and
great difficulty accessing Some members (e.g. All members can get All members are covered by
No medical coverage with 5 5
HEALTH CARE COVERAGE medical care when needed. Children) have medical medical care when needed affordable, adequate health
immediate need.
Some household members coverage. but may strain budget. insurance.
may be in poor health.
Unable to meet basic needs Can meet a few but not all Can meet most but not all Able to meet all basic needs Able to provide beyond
LIFE SKILLS such as hygiene, food, needs of daily living daily living needs without of daily living without basic needs of daily living 4 4
activities of daily living. without assistance. assistance. assistance. for self and family.
Family/friends may be Some support from
Has healthy/expanding
Lack of necessary support supportive but lack ability family/friends; family Strong support from family
support network; household
FAMILY / SOCIAL form family or friends; abuse or resources to help; family members acknowledge and or friends.
is stable, and 1 2
RELATIONS (DV, child) is present or there members do not relate well seek to change negative Household members
communication is
is child neglect. with one another; potential behaviors; are learning to support each other’s efforts.
consistently open.
for abuse or neglect. communicate and support.

Center for Community Action 195 Drive In Ln Everett, PA 15537 814-623-9129

CCA is an equal opportunity employer and provider.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CSBG INTAKE PACKET

Transportation is available,
Transportation is available
but unreliable,
No access to transportation, and reliable but limited Transportation is generally Transportation is readily
unpredictable, 1 4
MOBILITY public or private; may have and/or inconvenient; accessible to meet basic available and affordable; car
unaffordable; may have
car that is inoperable. drivers are licensed and travel needs. is adequately insured.
care but no insurance,
minimally insured.
license, etc.
Socially isolated and/or no
Transportation is generally
COMMUNITY Not applicable due to crisis; social skills and/or lacks Lacks knowledge of ways Actively involved in 1 5
accessible to meet basic
INVOLVEMENT in “survival” mode. motivation to become to become involved. community.
travel needs.
involved.
Some community
involvement (advisory
There are safety concerns Parenting skills are Parenting skills are group, support group), but Parenting skills are well n/a
PARENTING SKILLS n/a
regarding parenting skills. minimal. apparent but not adequate. has barriers such as developed.
transportation, childcare
issues.
Has successfully completed No active criminal justice
Current charges/trial
Current outstanding tickets or Fully compliant with probation/parole within involvement in more that 12 5 5
LEGAL pending, noncompliance
warrants. probation/parole terms. past 12 months, no new months and/or no felony
with probation/parole.
charges filed. criminal history.
Recurrent mental health
Symptoms are absent or
Danger to self or others; symptoms that may affect Mild symptoms may be
Minimal symptoms that are rare; good or superior
recurring suicidal ideation; behavior, but not a danger present but are transient;
expectable responses to life functioning in wide range of 3 3
MENTAL HEALTH experiencing severe difficulty to self/others; persistent only moderate difficulty in
stressors; only slight activities; no more than
in day-to-day life due to problems with functioning functioning due to mental
impairment in functioning. everyday problems or
psychological problems. due to mental health health problems.
concerns.
symptoms.
Meets criteria for Use within last 6 months;
dependence; evidence of persistent or Client has used during last 6
Meets criteria for severe preoccupation with use recurrent social, months, but no evidence of
abuse/dependence; resulting and/or obtaining occupational, emotional or persistent or recurrent
problems so severe that drugs/alcohol; withdrawal physical problems related social, occupational, No drug use/alcohol abuse 5 5
SUBSTANCE ABUSE
institutional living or or withdrawal avoidance to use (such as disruptive emotional, or physical in last 6 months.
hospitalization may be behaviors evident; use behavior or housing problems related to use; no
necessary. results in avoidance or problems); problems have evidence of recurrent
neglect of essential life persisted for at least one dangerous use.
activities. month.
Home or residence is not Safety is Current level of safety is Environment is safe,
safe; immediate level of threatened/temporary minimally adequate; however, future of such is Environment is apparently 2 5
SAFETY
lethality is extremely high; protection is available; level ongoing safety planning is uncertain; safety planning is safe and stable.
possible CPS involvement. of lethality is high. essential. important.
Vulnerable – sometimes or
In crisis – acute or chronic Safe – rarely has acute or Building Capacity –
periodically has acute or
symptoms affecting housing, chronic symptoms affecting asymptomatic – condition Thriving – no identified 3 3
DISABILITIES chronic symptoms affecting
employment, social housing, employment, controlled by services or disability.
housing, employment,
interactions, etc. social interactions, etc. medication
social interactions, etc.

OTHER (OPTIONAL) IN CRISIS VULNERABLE SAFE BUILDING CAPACITY EMPOWERED

Center for Community Action 195 Drive In Ln Everett, PA 15537 814-623-9129

CCA is an equal opportunity employer and provider.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CSBG INTAKE PACKET

CSBG ELIGIBILITY DETERMINATION

INTAKE INFORMATION
PROGRAM WORKER INITIALS FIRST NAME MIDDLE INITIAL LAST NAME

SC-COC Lori A Zeth

STREET ADDRESS CITY STATE ZIP MUNICIPALITY

223 Cherry St Roaring Springs PA 16673 n/a

SSN DOB AGE TEL FIRST CONTACT DATE

170-64-4259 11/01/83 38 814-660-9895 2/17/21

INTAKE DATE PRIMARY LANGUAGE DRIVERS LICENSE MILITARY STATUS OWN A VEHICLE?

3/9/21 English No Unknown / NR No

HOMEBOUND? MARITAL STATUS IN SCHOOL? ENROLLED SERVICES

No Separated No NONE

WORK STATUS/EMPLOYMENT HOUSING HOUSEHOLD TYPE

UNEMPLOYED (NOT IN LABOR FORCE) DOUBLED UP SINGLE PERSON

DISABILITY REGISTERED TO VOTE? GENDER EDUCATION

BOTH MENTAL/PHYSICAL NO FEMALE 12 GRADE / SOME POST-SECONDARY

RACE ETHNICITY

WHITE NOT HISPANIC, LATINO, OR SPANISH ORIGINS

HEALTH INSURANCE
MEDICAID MEDICARE CHIP STATE HEALTH MILITARY DIRECT-PURCHASE

EMPLOYMENT
UNKNOWN NOT REPORTED
BASED

INCOME TYPE
NO INCOME EMPLOYMENT SOCIAL SECURITY SSI SSD PRIVATE DISABILITY INS

WORKER’S COMP PENSION TANF CHILD SUPPORT ALIMONY PUBLIC/FOSTER CARE

VA SERVICE – CONNECTED DISABILITY

TRAINING PROGRAM/STIPEND VA SERVICE – CONNECTED DISABILITY PENSION
COMPENSATION

NON-CASH BENEFITS
HOUSING CHOICE
SNAP WIC LIHEAP PUBLIC HOUSING HUD-VASH
VOUCHER

PERMANENT SUPPORTIVE HOUSING CHILDCARE VOUCHER AFFORDABLE CARE ACT SUBSIDY OTHER

UNKNOWN/NOT REPORTED

Center for Community Action 195 Drive In Ln Everett, PA 15537 814-623-9129

CCA is an equal opportunity employer and provider.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CSBG INTAKE PACKET

ADDITIONAL HOUSEHOLD MEMBERS

PLEASE FILL OUT ONE CARD FOR EACH MEMBER OF THE HOUSEHOLD.

FIRST NAME MIDDLE INITIAL LAST NAME

STREET ADDRESS CITY STATE ZIP

SSN DOB AGE TEL

PRIMARY LANGUAGE DRIVERS LICENSE MILITARY STATUS OWN A VEHICLE?

HOMEBOUND? MARITAL STATUS IN SCHOOL? ENROLLED SERVICES

WORK STATUS/EMPLOYMENT LINK TO HOHH

DISABILITY REGISTERED TO VOTE? GENDER EDUCATION

RACE ETHNICITY

HEALTH INSURANCE
MEDICAID MEDICARE CHIP STATE HEALTH MILITARY DIRECT-PURCHASE

EMPLOYMENT
UNKNOWN NOT REPORTED
BASED

INCOME TYPE
NO INCOME EMPLOYMENT SOCIAL SECURITY SSI SSD PRIVATE DISABILITY INS

WORKER’S COMP PENSION TANF CHILD SUPPORT ALIMONY PUBLIC/FOSTER CARE

VA SERVICE – CONNECTED DISABILITY

TRAINING PROGRAM/STIPEND VA SERVICE – CONNECTED DISABILITY PENSION
COMPENSATION

NON-CASH BENEFITS
HOUSING CHOICE
SNAP WIC LIHEAP PUBLIC HOUSING HUD-VASH
VOUCHER

PERMANENT SUPPORTIVE HOUSING CHILDCARE VOUCHER AFFORDABLE CARE ACT SUBSIDY OTHER

UNKNOWN/NOT REPORTED

Center for Community Action 195 Drive In Ln Everett, PA 15537 814-623-9129

CCA is an equal opportunity employer and provider.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CSBG INTAKE PACKET

FIRST NAME MIDDLE INITIAL LAST NAME

STREET ADDRESS CITY STATE ZIP

SSN DOB AGE TEL

PRIMARY LANGUAGE DRIVERS LICENSE MILITARY STATUS OWN A VEHICLE?

HOMEBOUND? MARITAL STATUS IN SCHOOL? ENROLLED SERVICES

WORK STATUS/EMPLOYMENT LINK TO HOHH

DISABILITY REGISTERED TO VOTE? GENDER EDUCATION

RACE ETHNICITY

HEALTH INSURANCE
MEDICAID MEDICARE CHIP STATE HEALTH MILITARY DIRECT-PURCHASE

EMPLOYMENT
UNKNOWN NOT REPORTED
BASED

INCOME TYPE
NO INCOME EMPLOYMENT SOCIAL SECURITY SSI SSD PRIVATE DISABILITY INS

WORKER’S COMP PENSION TANF CHILD SUPPORT ALIMONY PUBLIC/FOSTER CARE

VA SERVICE – CONNECTED DISABILITY

TRAINING PROGRAM/STIPEND VA SERVICE – CONNECTED DISABILITY PENSION
COMPENSATION

NON-CASH BENEFITS
HOUSING CHOICE
SNAP WIC LIHEAP PUBLIC HOUSING HUD-VASH
VOUCHER

PERMANENT SUPPORTIVE HOUSING CHILDCARE VOUCHER AFFORDABLE CARE ACT SUBSIDY OTHER

UNKNOWN/NOT REPORTED

Center for Community Action 195 Drive In Ln Everett, PA 15537 814-623-9129

CCA is an equal opportunity employer and provider.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CSBG INTAKE PACKET

FIRST NAME MIDDLE INITIAL LAST NAME

STREET ADDRESS CITY STATE ZIP

SSN DOB AGE TEL

PRIMARY LANGUAGE DRIVERS LICENSE MILITARY STATUS OWN A VEHICLE?

HOMEBOUND? MARITAL STATUS IN SCHOOL? ENROLLED SERVICES

WORK STATUS/EMPLOYMENT LINK TO HOHH

DISABILITY REGISTERED TO VOTE? GENDER EDUCATION

RACE ETHNICITY

HEALTH INSURANCE
MEDICAID MEDICARE CHIP STATE HEALTH MILITARY DIRECT-PURCHASE

EMPLOYMENT
UNKNOWN NOT REPORTED
BASED

INCOME TYPE
NO INCOME EMPLOYMENT SOCIAL SECURITY SSI SSD PRIVATE DISABILITY INS

WORKER’S COMP PENSION TANF CHILD SUPPORT ALIMONY PUBLIC/FOSTER CARE

VA SERVICE – CONNECTED DISABILITY

TRAINING PROGRAM/STIPEND VA SERVICE – CONNECTED DISABILITY PENSION
COMPENSATION

NON-CASH BENEFITS
HOUSING CHOICE
SNAP WIC LIHEAP PUBLIC HOUSING HUD-VASH
VOUCHER

PERMANENT SUPPORTIVE HOUSING CHILDCARE VOUCHER AFFORDABLE CARE ACT SUBSIDY OTHER

UNKNOWN/NOT REPORTED

Center for Community Action 195 Drive In Ln Everett, PA 15537 814-623-9129

CCA is an equal opportunity employer and provider.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CSBG INTAKE PACKET

FIRST NAME MIDDLE INITIAL LAST NAME

STREET ADDRESS CITY STATE ZIP

SSN DOB AGE TEL

PRIMARY LANGUAGE DRIVERS LICENSE MILITARY STATUS OWN A VEHICLE?

HOMEBOUND? MARITAL STATUS IN SCHOOL? ENROLLED SERVICES

WORK STATUS/EMPLOYMENT LINK TO HOHH

DISABILITY REGISTERED TO VOTE? GENDER EDUCATION

RACE ETHNICITY

HEALTH INSURANCE
MEDICAID MEDICARE CHIP STATE HEALTH MILITARY DIRECT-PURCHASE

EMPLOYMENT
UNKNOWN NOT REPORTED
BASED

INCOME TYPE
NO INCOME EMPLOYMENT SOCIAL SECURITY SSI SSD PRIVATE DISABILITY INS

WORKER’S COMP PENSION TANF CHILD SUPPORT ALIMONY PUBLIC/FOSTER CARE

VA SERVICE – CONNECTED DISABILITY

TRAINING PROGRAM/STIPEND VA SERVICE – CONNECTED DISABILITY PENSION
COMPENSATION

NON-CASH BENEFITS
HOUSING CHOICE
SNAP WIC LIHEAP PUBLIC HOUSING HUD-VASH
VOUCHER

PERMANENT SUPPORTIVE HOUSING CHILDCARE VOUCHER AFFORDABLE CARE ACT SUBSIDY OTHER

UNKNOWN/NOT REPORTED

Center for Community Action 195 Drive In Ln Everett, PA 15537 814-623-9129

CCA is an equal opportunity employer and provider.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CSBG INTAKE PACKET

FIRST NAME MIDDLE INITIAL LAST NAME

STREET ADDRESS CITY STATE ZIP

SSN DOB AGE TEL

PRIMARY LANGUAGE DRIVERS LICENSE MILITARY STATUS OWN A VEHICLE?

HOMEBOUND? MARITAL STATUS IN SCHOOL? ENROLLED SERVICES

WORK STATUS/EMPLOYMENT LINK TO HOHH

DISABILITY REGISTERED TO VOTE? GENDER EDUCATION

RACE ETHNICITY

HEALTH INSURANCE
MEDICAID MEDICARE CHIP STATE HEALTH MILITARY DIRECT-PURCHASE

EMPLOYMENT
UNKNOWN NOT REPORTED
BASED

INCOME TYPE
NO INCOME EMPLOYMENT SOCIAL SECURITY SSI SSD PRIVATE DISABILITY INS

WORKER’S COMP PENSION TANF CHILD SUPPORT ALIMONY PUBLIC/FOSTER CARE

VA SERVICE – CONNECTED DISABILITY

TRAINING PROGRAM/STIPEND VA SERVICE – CONNECTED DISABILITY PENSION
COMPENSATION

NON-CASH BENEFITS
HOUSING CHOICE
SNAP WIC LIHEAP PUBLIC HOUSING HUD-VASH
VOUCHER

PERMANENT SUPPORTIVE HOUSING CHILDCARE VOUCHER AFFORDABLE CARE ACT SUBSIDY OTHER

UNKNOWN/NOT REPORTED

Center for Community Action 195 Drive In Ln Everett, PA 15537 814-623-9129

CCA is an equal opportunity employer and provider.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CSBG INTAKE PACKET

INTAKE INFORMATION (CONT.)

APPLICANT NAME Lori Zeth FAMILY ID #

ZETL0
ADDRESS CITY STATE ZIP

223 Cherry St Roaring Springs PA 16673

DEFINITION OF FAMILY UNIT; PERSONS RELATED BY BIRTH, MARRIAGE, OR ADOPTION WHO RESIDE TOGETHER. UNRELATED
PERSONS SUCH AS A LODGER, FOSTER CHILDREN, WARDS, OR EMPLOYEES WHO RESIDE WITH THE FAMILY UNIT ARE SEPARATE
FAMILY UNITS. EMANCIPATED MINORS ARE ALSO CONSIDERED AS SEPARATE FAMILY UNITS IN CALCULATING INCOME.
CERTIFICATION OF FOSTER CHILDREN OR WARDS OF THE COURT STATING THAT THE YOUTH IS A FOSTER CHILD OR WARD OF
THE COURT MAY INCLUDE LETTERS OR DOCUMENTS FROM THE COURT, CHILDREN’S SERVICE AGENCY, WELFARE OFFICE, FOSTER
PARENTS, OR SIMILAR ORGANIZATION.

FREQUENCY OF INCOME ELIGIBILITY DETERMINATION; FOLLOWING THE INITIAL DETERMINATION OF INCOME ELIGIBILITY,
REDETERMINATION MUST BE MADE EVERY 12 MONTHS FOR PERSONS RECEIVING CONTINUOUS SERVICE OR AT THE BEGINNING
OF EACH NEW CONTRACT YEAR, WHICHEVER COMES EARLIER. REDETERMINATION OF INCOME IS NECESSARY IF 90 DAYS ELAPSE
BEFORE ANY SERVICE IS PROVIDED. A REDETERMINATION OF INCOME IS ALSO NECESSARY IF THERE HAS BEEN A 90-DAY PERIOD
SINCE THE LAST SERVICE WAS PROVIDED. CLIENTS ENROLLED IN INTENSIVE CASE MANAGEMENT PROGRAMS TAKING MULTIPLE
PROGRAM YEARS TO REACH SELF-SUFFICIENCY DO NOT HAVE TO HAVE THEIR INCOME ELIGIBILITY DETERMINED EACH YEAR. THE
INITIAL INCOME DETERMINATION WILL DETERMINE ELIGIBILITY UNTIL THAT CLIENT EITHER REACHES SELF- SUFFICIENCY OR IS NO
LONGER A CLIENT.

TOTAL FAMILY INCOME IN THE PAST 90 DAYS (USD)

SALARIES/WAGES DIVIDENDS/INTEREST

0 0

UNEMPLOYMENT COMPENSATION OTHER CASH RECEIPTS (SS, SUPPORT, ETC.)

0 0

TOTAL INCLUDED INCOME

0

WELFARE PAYMENTS SUPPLEMENTAL SECURITY INCOME SOCIAL SECURITY DISABILITY (SSDI)

(SSI)
0 0 0

TRAINING PROGRAM STIPENDS PUBLIC FUNDS [FOR FOSTER CHILDREN/FAMILIES OR WARDS OF THE COURT]
0 0

TOTAL EXCLUDED INCOME

0

Center for Community Action 195 Drive In Ln Everett, PA 15537 814-623-9129

CCA is an equal opportunity employer and provider.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CSBG INTAKE PACKET

TOTAL INCLUDED 90 DAYS INCOME ANNUAL INCOME (X4)

0 0

CSBG REQUIREMENTS FOR ELIGIBILITY % ELIGIBLE

16100 125

IF ELIGIBLE, CHECK ONE TYPE OF ACCEPTABLE INCOME DOCUMENTATION

SALARY OR WAGE STATEMENT (EXAMPLE: W2)

STATEMENT SIGNED AND DATED FROM COUNTY ASSISTANCE OFFICE – COPY ATTACHED

STATEMENT SIGNED AND DATED FROM SOCIAL SECURITY ADMINISTRATION – COPY ATTACHED

DOCUMENTATION OF FAMILY’S WELFARE STATUS BASED ON ACCESS CARD FROM DPW – COPY ATTACHED

VERIFICATION OF INCOME RECEIVED FROM AN AGENCY PROVIDING SUBSIDIZED DAY CARE SERVICES/HOUSING – COPY
ATTACHED

SELF-DECLARATION – APPLICANT DOES NOT HAVE VERIFICATION OF FAMILY INCOME (1-5 ABOVE)

I CERTIFY THAT MY FAMILY’S INCOME INFORMATION AS LISTED ABOVE IS CORRECT. IF APPLICANT IS SELF-DECLARING FAMILY
INCOME [#6]: I ALSO CERTIFY THAT MY INCOME IN RELATION TO FAMILY SIZE DOES NOT EXCEED 125% OF THE FEDERAL POVERTY
GUIDELINES. I AM NOT ABLE TO PROVIDE INCOME VERIFICATION BECAUSE:

No income. Has not started receiving UC benefits from South Carolina

CLIENT SIGNATURE DATE

Mar 09 2021

CASE MANAGER SIGNATURE DATE

Mar 09 2021

Center for Community Action 195 Drive In Ln Everett, PA 15537 814-623-9129

CCA is an equal opportunity employer and provider.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CENTER FOR COMMUNITY ACTION
BEDFORD 814/623-9129
HUNTINGDON 814/643-4202
FULTON 717/325-4380

1 CAO Caseworker Karalynn

2 Eligible to apply for ESA at the CAO Yes No

3 If yes, refer to CAO for Emergency Shelter Assistance

4 Have you applied for heating assistance at the CAO Yes No

If no, reason for not applying

Caseworker’s determination of need: (Check all that apply)

Additional child
Lack of skills
Disaster
Current health issues
Inability to access services
Death in family
Divorce
Homeless
Job Loss
Substance abuse
Prison
Decreased Income
Education
Current disability
Lack of transportation
Economy
Homeless

Other (specify)

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CSBG INTAKE PACKET

MONTHLY LIVING EXPENSES

EXPENSE AMOUNT COMMENTS
MORTGAGE/RENT 0
FOOD 0
TOILETRIES 0
ELECTRIC 0
GAS 0
FUEL (OIL, WOOD) 0
TRASH 0
WATER/SEWER 0
PHONE/CELL 0
INTERNET 0
CABLE/SATELLITE 0
CAR PAYMENT 0
VEHICLE FUEL 0
CAR INSURANCE 0
LIFE INSURANCE 0
RENTER/HOMEOWNER INSURANCE 0
CHURCH 0
CLOTHING 0
MEDICAL/RX 0
LOANS 0
CREDIT CARDS 0
LAYAWAYS 0
RENT TO OWN 0
MEALS OUT 0
LAUNDRY 0
CIGARETTES 0
LEGAL/FINES 0
CHILDCARE 0
CHILD SUPPORT 0
DIAPERS/WIPES 0
STORAGE 0
ENTERTAINMENT 0
ALCOHOL 0
SELF CARE 0
TAXES 0
OTHER

MONTHLY EXP TOTAL: 0 NET MONTHLY INCOME 0 BALANCE 0

Center for Community Action 195 Drive In Ln Everett, PA 15537 814-623-9129

CCA is an equal opportunity employer and provider.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CSBG INTAKE PACKET

YES
AFFORDABILITY
NO

CLIENT SIGNATURE DATE

Mar 09 2021
CASE MANAGER SIGNATURE DATE
Mar 09 2021

Center for Community Action 195 Drive In Ln Everett, PA 15537 814-623-9129

CCA is an equal opportunity employer and provider.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Emergency Solutions Grant (ESG)

STAFF CERTIFICATION OF ELIGIBILITY FOR ESG ASSI

STANCE
Purpose: This form serves as documentation that: (1) the program participant named below meets all eligibility
criteria for ESG assistance; (2) this eligibility determination is based on true and complete information; (3) neither
the staff member making this determination nor his or her supervisor are related to the program participant
through family, business or other personal ties; and (4) this eligibility determination has not resulted from, nor will re
sult in, any financial benefit to the staff member making this determination, his or her supervisor, or anyone
related to them.

Instructions: This form must be completed for each program participant upon the determination of his or her
eligibility for ESG assistance. This form must be signed and dated by the ESG staff person who makes this
determination and that person’s supervisor and must be kept in the program participant’s case file. This form will
remain valid, unless a different staff person re‐determines the program participant’s eligibility, in which case a new
form will be required.

Head of Household Name:

Lori Zeth

Names of Other Household Members*:

Required certifications: Each person signing below certifies to the following: (1) To the best of my knowledge, th
e program participant named above meets all requirements to receive assistance under the Emergency Solutions
Grant (ESG). (2) To the best of my knowledge and ability, all of the information used in making this eligibility
determination is true and complete. (3) I am not related to the program participant through family, business or
other personal ties. (4) To the best of my knowledge, neither I nor anyone related to me has received or will
receive any financial benefit for this eligibility determination. (5) I understand that fraud is investigated by the
Department of Housing and Urban Development, Office of Inspector General, and may be punished under Federal l
aws to include, but not limited to, 18 U.S.C. 1001 and 18 U.S.C. 641. (6) I understand that if any of these
certifications is found to be false, I will be subject to criminal, civil and administrative penalties and sanctions.

Mar 09 2021
ESG Staff Signature: ____________________________________ Date: ______________________

Mar 09 2021
ESG Supervisor Signature: _______________________________ Date: ______________________

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Section 2

Case Notes

______ Referral Form

Income Limits (to be changed each year)

Homeless Certification –Homeless

Homeless Certification – Prevention
Self-Certification
Staff Certification
Chronic Homelessness
(Proof of homeless in this section)

Policy for calculating income

Proof of income will be filed here before income data worksheets

HMIS Data: Income 30 days or 90 days

(complete for each member in household)

Verification of Income

HMIS Data: Intake

(complete for each member in household)

Claim of Zero Income in Household

Resource Computation Worksheet

Lack of Resources and Supports Networks

Housing Stabilization Plan

HMIS Data: Housing Relocation and Stabilization

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CCA Referral Tracking Form

Already Date
Notes
Supportive Service Connected Referred
Health Care Services
County Assistance Office
Community Mental Health Provider
Community Medical Provider
Daily Living Services
Home Healthcare
Personal Finanical Planning
Credit Counseling
Financial Workshop
Tranportation Services
CART- CCA
PWD- CCA
Income Support Services
EARN
Employment and Training
Social Security
TANF
WIC
SNAP
Fiduciary/Payee Services
SSI Payee Services
Legal Services
Mid Penn Legal
Childcare
Early Learning Resource Center (ELRC) -CCA
Other
Area Agency on Aging
Love Inc.
St. Vincent De Paul
Weatherization Services
Your Safe Haven
Food Banks
VA
PCAP
Housing Authority

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Emergency Solutions Grant 2013

HOMELESS CERTIFICATION
Lori Zeth
ESG Applicant Name: ______________________________________________

Individual without dependent children (complete one form for each household)
Household with dependent children (complete one form for each head of household)
Number of persons in the household: _________
This is to certify that the above named individual or household is currently homeless based on the check mark, other indicate d
information, and signature indicating their current living situation. Check only ONE BOX and ONLY complete that section.
*IMPORTANT: THIRD PARTY EVIDENCE MUST BE ATTACHED TO THIS FORM IN ORDER TO CERTIFY HOMELESSNESS.

Living Situation: place not meant for human habitation (e.g., cars, parks, abandoned buildings, streets/sidewalks)

The person(s) named above is/are currently living in (or, if currently in hospital or other institution, was living in immediately
prior to hospital/institution admission) a public or private place not designed for, or ordinarily used as a regular sleeping
accommodation for human beings, including a car, park, abandoned building, bus station, airport, or camp ground.
Description of current living situation:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Homeless Street Outreach/Other Program (if applicable): _____________________________________________________________
This certifying agency must be recognized by the local Continuum of Care (CoC) as an agency that has a program designed to serve
persons living on the street or other places not meant for human habitation. (Examples may be street outreach workers, day
shelters, soup kitchens, Health Care for the Homeless sites, etc.)

Mar 09 2021
Authorized Referral Agency Representative Signature: __________________________________Date: ______________________

Living Situation: Emergency Shelter DV Shelter? (check if “yes”)

The person(s) named above is/are currently living in (or, if currently in hospital or other institution, was living in immediately
prior to hospital/institution admission) a supervised publicly or privately operated shelter as follows:

Emergency Shelter Program Name: _____________________________________________________________

This emergency shelter must appear on the CoC’s Housing Inventory Chart submitted as part of the most recent CoC Homeless
Assistance application to HUD or otherwise be recognized by the CoC as part of the CoC inventory (e.g. newly established Emergency
Shelter).

Mar 09 2021
Authorized Shelter Agency Representative Signature: _____________________________________Date: ______________________

Living Situation: Transitional Housing DV TH? (check if “yes”)

The person(s) named above is/are currently living in a transitional housing program for persons who are homeless. The
persons(s) named above is/are graduating from or timing out of the transitional housing program:

Transitional Housing Program Name: ____________________________________________________________

Immediately prior to entering transitional housing the person(s) named above was/were residing in:
emergency shelter OR a place unfit for human habitation

Mar 09 2021
Authorized Transitional Housing Agency Representative Signature: ____________________________Date: ____________________

Living Situation: Market Housing

The person(s) named above was/were evicted from or otherwise lost housing obtained through the private market.
Landlord or other Third Party Signature: __________________________________Date: ____________________
Mar 09 2021

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Emergency Solutions Grant 2013

AT-RISK HOMELESS CERTIFICATION (for Homelessness Prevention)

Lori Zeth
ESG Applicant Name: ______________________________________________
Address from which Applicant is being evicted: ____________________________________________________________
233 Cherry St, Roaring Springs, PA 16673

Individual without dependent children (complete one form for each household)
Household with dependent children (complete one form for each head of household)
Number of persons in the household: _________
1

This is to certify that the above named individual or household is currently at risk for homeless based on the
information indicated below and signature indicating their current housing status.
*IMPORTANT: THIRD PARTY EVIDENCE, INCLUDING WRITTEN STATEMENTS, [(B) and (C) below], MUST BE ATTACHED TO THIS
FORM IN ORDER TO CERTIFY AT-RISK STATUS.

Living Situation: Facing Eviction

The person/household named above is currently living in rental housing from which he/she/they is/are being
evicted. ESG assistance provided will not overlap with other federal funding sources.

The individual or family:

1. Has income below 30 percent of median income for the geographic area (see income documentation form); AND
2. Lacks sufficient resources to attain housing stability. [e.g., family, friends, faith-based or other social networks
immediately available] to prevent them from moving to an emergency shelter or another place described in category 1
of the homeless definition.

Evidence of the second eligibility criterion (#2 above) for this Applicant is:

(A) Source documents (e.g., notice of termination from employment, unemployment compensation statement, bank
statement, health-care bill showing arrears, utility bill showing arrears).
(B) To the extent that source documents are unobtainable, a written statement by the relevant third party (e.g.,
former employer, public administrator, relative) or written certification by the intake staff of the oral verification by the
relevant third party that the applicant meets one or both of the criteria of the definition of ‘‘at risk of homelessness’’ or
(C) If source documents and third-party verification are unobtainable, a written statement by intake staff describing
the efforts taken to obtain the required evidence.

The person(s) listed above meet one or more of the following risk factors:

(1) Has moved frequently because of economic reasons

(2) Is living in the home of another because of economic hardship
(3) Has been notified in writing that their right to occupy their current housing or living situation will be
terminated within 21 days after the date of application
(4) Lives in a hotel or motel; “and the cost of the hotel or motel is not paid for by federal, state, or local
government programs for low-income individuals or by charitable organizations’’
(5) Lives in severely overcrowded housing; (in a single-room occupancy or efficiency apartment unit in which
more than two persons, on average, reside or another type of housing in which there reside more than 1.5 persons per
room, as defined by the U.S. Census Bureau.)
(6) Is exiting a publicly funded institution; or system of care, (such as a health-care facility, mental health
facility, foster care or other youth facility, or correction program or institution)
(7) Otherwise lives in housing that has characteristics associated with instability and an increased risk of
homelessness

continued…

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Emergency Solutions Grant 2013

Evidence of risk factors for this Applicant is:

(A) Source documents (e.g., notice of termination from employment, unemployment compensation statement, bank
statement, health-care bill showing arrears, utility bill showing arrears).
(B) To the extent that source documents are unobtainable, a written statement by the relevant third party (e.g.,
former employer, public administrator, relative) or written certification by the intake staff of the oral verification by the
relevant third party or
(C) If source documents and third-party verification are unobtainable, a written statement by intake staff describing
the efforts taken to obtain the required evidence.

Third Party Certification

I certify that I have provided verification as indicated above that the ESG Applicant meets eligibility criteria and/or risk
factors for being “at-risk” of homelessness.

Relevant Third-Party Representative Signature: ___________________________________Date: ___________________

ESG Staff Signature: _______________________________________ Mar 09 2021

Date: ______________________

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Emergency Solutions Grant 2013

SELF CERTIFICATION OF HOMELESS/DOMESTIC VIOLENCE/ AT RISK

Lori Zeth
ESG Applicant Name: ______________________________________________

Household without dependent children (complete one form for each household)
Household with dependent children (complete one form for each head of household)
Number of persons in the household: _________
1

This is to certify that the above named individual or household is currently homeless based on the check mark, other
indicated information, and signature indicating their current living situation.

Check only one:

I [and my children] am/are currently homeless and living on the street (i.e. a car, park, abandoned
building, bus station, airport, or camp ground).

I [and my children] am/are the victim(s) of domestic violence and am/are fleeing from abuse, have not
identified a subsequent residence, and lack the resources or support networks, e.g., family, friends, faith-
based, or other social networks, needed to obtain housing where my/our safety would not be jeopardized.

I [and my children] am/are being evicted from the housing we are presently staying in and must leave this
housing within the next 14 days.

I certify that I have insufficient financial resources and support networks; e.g., family, friends, faith-based or
other social networks, immediately available to obtain housing or to attain housing stability without ESG
assistance. I certify that the information above and any other information I have provided in applying for
ESG assistance is true, accurate and complete.

ESG Applicant Signature: ___________________________________ Mar 09 2021

Date: ______________________

ESG Staff Certification

I understand that third-party verification is the preferred method of certifying homelessness or risk for
homelessness for an individual who is applying for ESG assistance. I understand self declaration is only
permitted when I have attempted to but cannot obtain third party verification.

Documentation of attempts made for third-party verification:

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

ESG Staff Signature: _______________________________________ Mar 09 2021

Date: ______________________

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Emergency Solutions Grant 2013

STAFF CERTIFICATION OF HOMELESS/DOMESTIC VIOLENCE/ AT RISK

[Oral third party verification]
I understand that securing third party documentation is the preferred method of certifying homelessness or risk for
homelessness for an individual who is applying for ESG assistance, but cannot obtain source documents. Below I am
providing details of oral third party verification of eligibility or risk factors and certifying all statements to be true,
accurate and complete.

Oral verification by the relevant third party was made on ______________ (date) through a conversation with
_____________________________________ (Relevant Third-Party Representative)

Verification of homelessness was provided:

Over the phone In person
Regarding _______________________________________ (ESG applicant)

The following information was provided regarding the ESG applicant’s homeless status, victim status and available
resources:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
I understand that obtaining third party verification of eligibility or risk factors is the preferred method of certifying
eligibility for an individual who is applying for ESG assistance, but cannot meet this standard. I made the following
efforts to obtain third party verification:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Mar 09 2021
ESG Staff Signature: _______________________________________ Date: ______________________

[Staff/Intake worker observation verification]

I have observed the following conditions which serve as evidence related to the applicant’s housing status, victim status
and available resources. Due to the following factors I certify this applicant’s eligibility for ESG assistance.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

I understand that obtaining third party verification of eligibility or risk factors is the preferred method of certifying
eligibility for an individual who is applying for ESG assistance, but cannot meet this standard. I made the following
efforts to obtain third party verification:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Mar 09 2021
ESG Staff Signature: _______________________________________ Date: ______________________
eversign Document Hash: ad28d070a36f48db9eec14d06857c90f
Emergency Solutions Grant 2013

CERTIFICATION OF CHRONIC HOMELESSNESS

This document may be used to analyze whether or not an individual or family meets the definition of chronic
homelessness. Documentation must be attached to verify status.
Lori Zeth
ESG Applicant Name: ______________________________________________
Household without dependent children (complete one form for each household)
Household with dependent children (complete one form for each head of household)
Number of persons in the household: _________

Applicant or head of household has the following disability based on the condition(s): (check all that apply)
A diagnosable substance abuse disorder
A serious mental illness
A developmental disability
A chronic physical illness or disability, including the co-occurrence of two or more of these conditions.

AND
Has been literally homeless:
For at least 1 year or
On at least four separate occasions in the last 3 years, where each occasion lasted for at least 15 days or
Continuously unsheltered or
Living in a shelter for past 1 year, or
This is the 4th separate occurrence of this living situation in the past 3 years

Time Period Time Number

Beginning Period End of Days Location of Stay Documented?
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Total days
Based on this summary, I certify that the client: is chronically homeless is not chronically homeless.

ESG Staff Signature: _______________________________________ Mar 09 2021

Date: ______________________

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Emergency Solutions Grant 2013

SELF-STATEMENT OF CHRONIC HOMELESSNESS

Third-party verification of chronic homelessness is always preferred; however, this document of Self-Statement may be
used when a homeless person/household applying for ESG assistance lacks the connections with service providers
necessary to complete a Third Party Verification of chronic homelessness. Documentation must be attached to verify
status.
Lori Zeth
ESG Applicant Name: ______________________________________________
Household without dependent children (complete one form for each household)
Household with dependent children (complete one form for each head of household)
Number of persons in the household: _________

Applicant or head of household has the following disability based on the condition(s): (check all that apply)
A diagnosable substance abuse disorder
A serious mental illness
A developmental disability
A chronic physical illness or disability, including the co-occurrence of two or more of these conditions.

AND
Has been literally homeless:
For at least 1 year or
On at least four separate occasions in the last 3 years, where each occasion lasted for at least 15 days or
Continuously unsheltered or
Living in a shelter for past 1 year, or
This is the 4th separate occurrence of this living situation in the past 3 years

I certify that I was homeless (sleeping in a place not meant for human habitation such as living on the streets) OR living
in a homeless emergency shelter during the following period(s) of time:

Time Period Time Period Number

(Beginning) (End) of Days Location of Stay

Total days

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Emergency Solutions Grant 2013

What else would you like to share about your history? For example, “I cannot remember the name of the place where I was
living during the fall of 2012 but I believe that it was a homeless emergency shelter. I have problems with my memory from
that time due to an illness.”
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________
I certify that the above information is correct.

Mar 09 2021
ESG Applicant Signature: ___________________________________ Date: ______________________

ESG Staff Certification

I understand that third-party verification is the preferred method of certifying homelessness or risk for homelessness for
an individual who is applying for ESG assistance. I understand self declaration is only permitted when I have attempted
to but cannot obtain third party verification.

Documentation of attempts made for third-party verification:

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
___________________________________________________________

ESG Staff Signature: _______________________________________ Date: ______________________

Mar 09 2021

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Emergency Solutions Grant 2013

CHRONIC HOMELESS CERTIFICATION

Lori Zeth
I certify that the signed individual below, _________________________________ (Client Name)
previously resided at _______________________________________ (Facility Name)

For the following period(s) of time within the last three (3) years:

Time Period Time Period Number

(Beginning) (End) of Days Location of Stay

Total days

This facility is classified as one of the following types of institutions:

Emergency Shelter
Transitional Housing
Place not meant for human habitation
Permanent Supportive Housing
Medical Institution
Mental Health Institution
Correctional Facility
Substance Abuse Facility
Other: ___________________________

I further certify that immediately prior to entering this facility the person named above was residing at/in:

______________________________________

Authorized Third Party Signature: ___________________________________ Date: ______________________

I hereby authorize the release of this information:

Mar 09 2021
ESG Applicant Signature: ___________________________________ Date: _________________________

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CSBG INTAKE PACKET

PROOF OF INCOME
INCOME CALCULATION
CALCULATING INCOME FOR THE PAST 30 DAYS:

1) ADD THE GROSS INCOME IN THE 30 DAYS PRIOR TO THE DATE OF THE APPLICATION (FROM ALL SOURCES, BEFORE
DEDUCTIONS) TO ARRIVE AT A TOTAL.
2) DIVIDE THE TOTAL BY THE NUMBER OF WEEKS IN THE 30-DAY PERIOD. USE THE WEEKLY AVERAGE AS A REPRESENTATIVE
WEEK.
3) MULTIPLY THE REPRESENTATIVE WEEK BY 52 TO ARRIVE AT AN ESTIMATED ANNUAL GROSS INCOME OR MULTIPLY BY 4.33
TO ARRIVE AT AN ESTIMATED MONTHLY GROSS INCOME.

AFTER ANNUALIZING THE LAST 30 DAYS OF INCOME, IF THE CLIENT IS NOT ELIGIBLE DUE TO EXCEPTIONAL CIRCUMSTANCES (FOR
INSTANCE, RECEIVING EXTRA PAY DURING THE 30 DAYS, OVERTIME, FLUCTUATING PAY, ETC.) INCOME WILL THEN BE
CALCULATED USING 90 DAYS OF GROSS INCOME.

CALCULATING INCOME FOR THE PAST 90 DAYS:

1) ADD THE GROSS INCOME IN THE 90 DAYS PRIOR TO THE DATE OF THE APPLICATION (FROM ALL SOURCES, BEFORE
DEDUCTIONS) TO ARRIVE AT A TOTAL.
2) DIVIDE THE TOTAL BY THE NUMBER OF WEEKS IN THE 90 DAY PERIOD. USE THE WEEKLY AVERAGE AS A REPRESENTATIVE
WEEK.
3) MULTIPLY THE REPRESENTATIVE WEEK BY 52 TO ARRIVE AT AN ESTIMATED ANNUAL GROSS INCOME OR MULTIPLY BY 4.33
TO ARRIVE AT AN ESTIMATED MONTHLY GROSS INCOME.

Center for Community Action 195 Drive In Ln Everett, PA 15537 814-623-9129

CCA is an equal opportunity employer and provider.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CSBG INTAKE PACKET

INCOME GOING BACK 30 DAYS

APPLICANT NAME SIGNED DATE START DATE END DATE

Lori Zeth Mar 09 2021 3/9/21 4/9/21

HEAD HOUSEHOLD MEMBER

SOURCE DATE PAID GROSS AMOUNT

EARNED INCOME 0

EARNED INCOME 0

SELF-EMPLOYMENT 0

INTEREST/DIVIDENDS 0

PENSION/RETIREMENT 0

UNEMLPOYMENT 0

TANF/ASSISTANCE 0

ALIMONY/CHILD SUPPORT 0

ALIMONY/CHILD SUPPORT 0

0
OTHER

OTHER 0

OTHER HOUSEHOLD MEMBER

SOURCE DATE PAID GROSS AMOUNT

EARNED INCOME

EARNED INCOME

SELF-EMPLOYMENT

INTEREST/DIVIDENDS

Center for Community Action 195 Drive In Ln Everett, PA 15537 814-623-9129

CCA is an equal opportunity employer and provider.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CSBG INTAKE PACKET

PENSION/RETIREMENT

UNEMLPOYMENT

TANF/ASSISTANCE

ALIMONY/CHILD SUPPORT

ALIMONY/CHILD SUPPORT

OTHER

OTHER

TOTAL AMOUNT (HOH) 0 TOTAL AMOUNT (OTHER)

GRAND TOTAL 0

1 NO. OF WEEKS IN PAY PERIOD 2 REPRESENTATIVE WEEK $

4 0

3 EST. MONTHLY GROSS INCOME (FIELD 2 X 4.33) 4 ESTIMATED ANNUAL GROSS INCOME (FIELD 2 X 52)

0 0

FAMILY SIZE MONTHLY INCOME LIMIT ANNUAL INCOME LIMIT

1
1342 16100

INCOME ELIGIBLE?

CLIENT SIGNATURE DATE

Mar 09 2021

CASE MANAGER SIGNATURE DATE

Mar 09 2021

Center for Community Action 195 Drive In Ln Everett, PA 15537 814-623-9129

CCA is an equal opportunity employer and provider.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Emergency Solutions Grant (ESG)
VERIFICATION OF INCOME
Lori Zeth
ESG Applicant Name: ______________________________________________

Instructions for Employer/Payment Source Representative: This is to certify the income received by the above named
individual for purposes of participating in the ESG program. This information will be used only to determine the eligibility
status and level of benefit of the household. Complete only the selected section below that includes an authorization
to release information.

Please return this form to:

Name & Title: __________________________________ Phone: ____________________________
Address: __________________________________ Fax: ____________________________
Email: __________________________________

Employment Income

ESG Applicant Release: I hereby authorize the release of the following employment information.
ESG Applicant Signature: _______________________________ Date: ______________________
Mar 09 2021

Employer representative to complete this section:

The person named above is employed by ______________________________________since _______________. He/she
is paid $______________ on a _____________basis and is currently working an average of _____________hours per
____________.

Additional compensation please specify (if any):__________________________________________________________

Probability of continued employment: ________________________________________________________________

Authorized Employer Representative Signature: ____________________________________ Date:__________________

Name, Title: _______________________________________________________________________________________
Address and Phone: _________________________________________________________________________________

Payments and/or Benefit Income (complete one form for each distinct source of income for person named above)

CIRCLE ONE: Social Security/SSI Pension /Retirement TANF

Public Assistance Unemployment Compensation Workers Compensation
Alimony Payments Foster Care Payments Child Support Payments
Armed Forces Income
Other (pls. specify): ___________________________________________________________

ESG Applicant Release: I hereby authorize the release of the following payment and/or benefit information.
ESG Applicant Signature: _______________________________ Date: ______________________
Mar 09 2021

Payment source representative to complete this section:

Payments or benefits in the amount of $_______________________ are paid on a ______________________ basis. The
expected duration of the payments or benefits is _____________________________.

Authorized Payment Source Representative Signature: _______________________________ Date:_________________

Name, Title: ______________________________________________________________________________________
Address and Phone: _______________________________________________________________________________

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CSBG INTAKE PACKET

CLAIM OF ZERO INCOME IN HOUSEHOLD

I,Lori Zeth
, STATE THAT NO MEMBER OF MY HOUSEHOLD
HAS RECEIVED ANY SOURCE OF INCOME DURING THE PAST 30 DAYS. OUR HOUSEHOLD HAS
BEEN WITHOUT INCOME SINCE I EXPECT TO RECEIVE
SOME INCOME ON OR ABOUT FROM

SOURCE OF EXPECTED INCOME

South Carolina unemployment

I UNDERSTAND THAT I CAN BE DENIED AND/OR TERMINATED FROM ANY ASSISTANCE FOR
MAKING FALSE STATEMENTS AND I DO AFFIRM THAT ALL CLAIMS MADE HERE ARE COMPLETE
AND TRUTHFUL TO THE BEST OF MY KNOWLEDGE.

PROVIDING FALSE INFORMATION OR KNOWINGLY OMITTING INFORMATION

CONSTITUTES FRAUD AND WILL BE REPORTED TO THE OFFICE OF INSPECTOR GENERAL.

CLIENT SIGNATURE DATE

Mar 09 2021

CASE MANAGE SIGNATURE DATE

Mar 09 2021

Center for Community Action 195 Drive In Ln Everett, PA 15537 814-623-9129

CCA is an equal opportunity employer and provider.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

RESOURCE COMPUTATION WORKSHEET

Applicant Name Application Signed Date Start Date End Date

3/9/21
Lori Zeth
Mar 09 2021

Readily Available Resources Value

0
CASH $

0
SAVINGS ACCOUNT $

0
INCOME TAX REFUND $

0
SAVINGS BONDS $

0
STOCK CERTIFICATES $

0
CERTIFICATES OF DEPOSIT $

0
OTHER LIQUID ASSETS $

0
OTHER $

OTHER 0
$

0
OTHER $

0
The amount available to assist the current crisis: $

Are readily available resources sufficient to resolve housing crisis? Yes No

Is the applicant income eligible? Yes No

Mar 09 2021
Consumer Signature: Date:

Case Manager Signature: Date: Mar 09 2021

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Lack of Resources and Support Networks
CENTER FOR COMMUNITY ACTION
BEDFORD 814/623-9129
HUNTINGDON 814/643-4202
FULTON 717/325-4380

By signing this form, I am attesting that I or my family lack any financial resources
or support networks (family or friends) needed to obtain housing. Therefore,
without assistance from Center for Community Action, I or my family will
become/remain homeless.

I am also willing to provide the agency with all financial records to prove
household income and resources.

I understand that providing any false information could result in termination from
the agency program and/or legal action taken against me.

Providing false information or knowingly omitting information constitutes

fraud and will be reported to the Office of Inspector General.

Mar 09 2021

Head of Household Signature Date

Other Adult Household Member Date

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CSBG INTAKE PACKET

FAMILY GOAL ACTION PLAN

CLIENT NAME DATE OF PLAN REVIEW DATE

Lori Zeth 3/9/21

WHAT ARE SOME BARRIERS YOU ARE FACING?

Facing eviction and homelessness. Has not started receiving SC unemployment benefits

WHAT HAS PUT YOU IN THIS SITUATION AND WHAT THREATENS YOUR STABILITY?

Moved from SC and lost her job and housing.

WHAT ARE SOME STRENGHTS AND WEAKNESSES THAT CAN HELP YOU OVERCOME YOUR SITUATION?

Motivated and determined and has a support system set up.

WHAT HAS PREVENTED YOU FROM SAVING MONEY IN THE PAST?

Living pay check to paycheck

WHAT HAS HELPED YOU SAVE MONEY IN THE PAST?

Having steady income and budgeting

HOW WILL YOU MAINTAIN YOUR BUDGET (INCREASE INCOME/DECREASE SPENDING)?

Budgeting and paying necessities first

Center for Community Action 195 Drive In Ln Everett, PA 15537 814-623-9129

CCA is an equal opportunity employer and provider.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CSBG INTAKE PACKET

OBJECTIVES
CLIENT NAME
Lori Zeth

OBJECTIVE #1
Find Housing

WHAT PURPOSE WHO BY WHEN

CCA find housing Lori 4/9/21

HUD subsidy housing Lori 4/9/21

Internet Find housing Lori 4/9/21

CLIENT NAME
Lori Zeth

OBJECTIVE #2
Find employment

WHAT PURPOSE WHO BY WHEN

Careerlink Employment Lori 5/9/21

Internet " Lori 5/9/21

Newpaper " Lori 5/9/21

Center for Community Action 195 Drive In Ln Everett, PA 15537 814-623-9129

CCA is an equal opportunity employer and provider.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CSBG INTAKE PACKET

CLIENT NAME
Lori Zeth

OBJECTIVE #3
Apply for subsidies

WHAT PURPOSE WHO BY WHEN

LiHeap heating assistance Lori 4/9/21

Hud Housing assistance Lori 4/9/21

PCAP energy assistance Lori 4/9/21

CLIENT NAME
Lori Zeth

OBJECTIVE #4
Develop a budget

WHAT PURPOSE WHO BY WHEN

CCA Develop a budget Lori 5/9/21

Internet " Lori 5/9/21

CAO " Lori 5/9/21

Center for Community Action 195 Drive In Ln Everett, PA 15537 814-623-9129

CCA is an equal opportunity employer and provider.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CSBG INTAKE PACKET

CLIENT NAME
Lori Zeth

I AGREE WITH THIS FAMIL GOALS ACTION PLAN

I HAVE BEEN OFFERED A COPY OF THIS FAMILY GOALS ACTION PLAN

I ACCEPTED MY OWN COPY OF THE PLAN

I DECLINED MY OWN COPY OF THE PLAN

CLIENT SIGNATURE DATE

Mar 09 2021

CASE MANAGER SIGNATURE DATE

Mar 09 2021

Center for Community Action 195 Drive In Ln Everett, PA 15537 814-623-9129

CCA is an equal opportunity employer and provider.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Section 3

Copy of Fair Market Rent for appropriate County

Pictures of unit

Rent Reasonableness Checklist and Certification

Housing Inspection Report

Habitability Standards Inspection Checklist

Lead Screening Worksheet

(complete lead screening even if constructed after 1978 or no children)

Lead Based Paint Visual Assessment Certification

Lead Based Paint Property Owner Certification

(completed by property owner ONLY if lead based paint was identified)

Lead Based Paint Brochure

(given to consumers prior to signing the information acknowledgement)

Lead Information Acknowledgement

(signed by consumer and Case Manager)

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Fair Market Rents 2021

BEDFORD COUNTY
Year Efficiency One-Bedroom Two- Bedroom Three-Bedroom Four- Bedroom
FY 2021 FMR $571 $592 $724 $934 $1,034
FY 2020 FMR $571 $602 $714 $907 $999

FULTON COUNTY
Year Efficiency One-Bedroom Two- Bedroom Three-Bedroom Four- Bedroom
FY 2021 FMR $537 $635 $724 $950 $1,208
FY 2020 FMR $532 $627 $714 $938 $1,153

HUNTINGDON COUNTY
Year Efficiency One-Bedroom Two- Bedroom Three-Bedroom Four- Bedroom
FY 2021 FMR $571 $609 $724 $978 $1,085
FY 2020 FMR $532 $599 $714 $970 $1,079

MIFFLIN COUNTY
Year Efficiency One-Bedroom Two- Bedroom Three-Bedroom Four- Bedroom
FY 2021 FMR $521 $616 $724 $970 $1,216
FY 2020 FMR $533 $610 $714 $952 $1,103

ADAMS COUNTY
Year Efficiency One-Bedroom Two- Bedroom Three-Bedroom Four- Bedroom
FY 2021 FMR $696 $802 $974 $1,314 $1,574
FY 2020 FMR $640 $739 $911 $1,216 $1,481

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

RENT REASONABLENESS CHECKLIST AND CERTIFICATION

Proposed Unit Unit #1 Unit #2 Unit #3

Address 1424 Overland Pass
Claysburg, Pa 16673

Number of Bedrooms 1

Square Feet unknown

Type of Unit/Construction efficiency

Housing Condition Good

Location/Accessibility
Claysburg

Amenities All utilites included

Unit:

Site:

Neighborhood:
Age in Years Unknown

Utilities (type) electric

Unit Rent
Utility Allowance 571
Gross Rent
Handicap Accessible? unknown

CERTIFICATION:

A. Compliance with Payment Standard

571 0 571
____________________ _____________ __________________
Proposed Contract Rent + Utility Allowance = Proposed Gross Rent

Approved rent does not exceed applicable Payment Standard of

571
$_____________.

B. Rent Reasonableness

Based upon a comparison with rents for comparable units, I have determined that the
proposed rent for the unit [ ]is [ ] is not reasonable.

Name: Terushia Jackson Signature: Date:

Mar 09 2021

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Housing Inspection Report
Lori Zeth 3/9/21
Client name: ______________________________________________ Date _________________
3/9/21
Date of Inspection ________________ Pass _____ Fail _____ Case # __________________
The American Trust/ Gordon Schaaf
Landlord Name _______________________________________________

Location of Unit 1424 Overland Pass, Claysburg, PA 16625, Unit #L401

____________________________________________ Date Built ___________
unknown

Altoona City Code and Residential Unit License Number _________________________________

Code Office {814} 949-2456
Terushia Jackson
_________________________________
Case Manager

Living room
Ceiling Good Condition ____ Deficient _____
List deficiencies

Walls Good Condition _____ Deficient _____

List deficiencies

Electricity Good Condition _____ Deficient _____

List deficiencies

Floor Good Condition _____ Deficient _____

List deficiencies

Paint Good Condition _____ Deficient _____ Peeling _____ Flaking _____ Cracking ____
List deficiencies

Doors Good Condition _____ Deficient _____ Rubbing causing paint flakes or dust ____
List deficiencies

Windows Good Condition _____ Deficient _____ Rubbing causing paint flakes or dust ____
List deficiencies

Kitchen
Ceiling Good Condition _____ Deficient _____
List deficiencies

Storage Good Condition _____ Deficient _____

List deficiencies

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Electricity Good Condition _____ Deficient _____
List deficiencies

Stove/ Oven Good Condition _____ Deficient _____

List deficiencies

Floor Good Condition _____ Deficient _____

List deficiencies

Preparation / Good Condition _____ Deficient _____

Serving area List deficiencies

Window Good Condition _____ Deficient _____ Rubbing causing paint flakes or dust _____
List deficiencies

Paint Good Condition _____ Deficient _____ Peeling ____ Flaking ____ Cracking ____
List deficiencies

Walls Good Condition _____ Deficient _____

List deficiencies

Refrigerator Good Condition _____ Deficient _____

List deficiencies

Sink Good Condition _____ Deficient _____

List deficiencies

Bathroom
Ceiling Good Condition _____ Deficient _____
List deficiencies

Electricity Good Condition _____ Deficient _____

List deficiencies

Paint Good Condition _____ Deficient _____ Peeling ___ Flaking ___ Cracking ___
List deficiencies

Floor Good Condition _____ Deficient _____

List deficiencies

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Walls Good Condition _____ Deficient _____
List deficiencies

Doors Good Condition _____ Deficient _____ Rubbing causing paint flakes or dust ____
List deficiencies

Windows Good Condition _____ Deficient _____ Rubbing causing paint flakes or dust ____

Exhaust Window _____ Fan _____

Toilet Good Condition _____ Deficient _____

Tub/Shower Good Condition _____ Deficient _____

Sink Good Condition _____ Deficient _____

Bedrooms
Bedroom #1 Bedroom #2 Bedroom #3 Bedroom #4 Bedroom #5
Ceiling Good
Deficient
Electricity Good
Deficient
Paint Good
Deficient
Peeling
Flaking
Cracking
Walls Good
Deficient
Floor Good
Deficient
Doors Good
Deficient
Rubbing causing
paint flakes or
dust
Windows Good
Deficient
Rubbing causing
paint flakes or
dust

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Closets Good Condition _____ Deficient _____

Exterior, Plumbing and Heating

Roof Good Condition _____ Deficient _____

Exterior walls Good Condition _____ Deficient _____

Foundation Good Condition _____ Deficient _____

Water heater Good Condition _____ Deficient _____

Heat supply Good Condition _____ Deficient _____

Health and Safety

Fire Alarm/Smoke Detectors Installed and in Good Condition Yes

Yes
Carbon Monoxide Detectors Installed and in Good Condition

Alternate means of egress in case of fire Yes _____ No _____

Mar 09 2021
________________________________________ ______________
Client Signature Date

Mar 09 2021
________________________________________ ______________
Inspector Signature Date

________________________________________ _______________
Landlord Signature Date

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Acceptable Standard for Inspection of Residential Housing

INTERIOR
General inspection of apartments and house requires safe buildings materials, safe electrical fixtures,
sufficient water supply, healthy sanitations and fire safety.

Walls, ceilings, floors shall not consist of large cracks, holes, missing boards, falling plaster or severe
bulging.

Windows will not be nailed precluding exit in time of emergency. Windows which are broken badly
cracked or missing panes are not acceptable. Windows which shall not shut or when shut, do not keep
out weather in addition to windows painted with chipped, peeling or turning to dust caused by friction
are not acceptable .

Each room shall at a minimum contain two electrical outlets [with two plug jacks], or one outlet and one
permanent overhead light fixture.
Broken and/or frayed wiring, light fixtures hanging from wires with no firm support are not acceptable.
All outlets shall have plates in good condition covering the outlet.

Refrigerators shall keep temperatures which prevent food spoilage.

Kitchen and bathroom sinks shall provide hot and cold running water.

EXTERIOR PLUMBING HEATING

Roofs shall not leak. Gutters and downspouts are not required but, if present, are in good condition and
securely attached to the building. Evidence of leaks can usually be seen from stains on the ceiling inside
the building.

Exterior walls shall not have missing bricks planks or chipped and peeling paint if built before 1978.

Chimneys shall not have any serious leaning or defects such as missing bricks or big cracks in the
masonry.

The water heater shall be located, equipped and installed in a safe manner.

Heat shall be provided which will make the unit comfortable during cold months. Space heaters are not
acceptable that burn oil or gas and not vented to a chimney. Space heater that is vented may be
acceptable if they can provide enough heat. Electric heaters are acceptable.

HEALTH AND SAFETY

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Smoke detectors shall be installed on each level or the unit, including the basement or basement
stairway. If any member of the family is hearing impaired, the smoke detector must have an alarm
system for hearing impaired persons.

In apartment units the fire exits must be marked and alternate means of exit in case of fire is necessary.

Entrances from the outside or from a public hall it must not be necessary to go through anyone else’s
private apartment to get to the unit.

Garbage must be contained in a closed container at all times. Trash shall be picked up on a regular
basis.

Lights shall be working 24/7 in all common hallways and interior stairs.

Handrails shall be installed on any extended length of stairs and any porches, balconies or decks which
are 30 inches or more above the ground.

** If there will be any children age 6 years or younger residing in the unit,
the inspection will be done by our agency’s certified lead inspector.

Mobile Home
Mobile homes must be placed on a site in a stable manner and free from hazards such as sliding or wind
damage.

Mobile homes must also meet local standards for sewerage usually located on a sand pile.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Form #: ESG-216
 

ESG Housing Habitability Standards  
Inspection Checklist  

About this Tool  

The standards for housing unit inspections under ESG are the housing 
habitability standards described in the HUD ESG Interim Rule.  These 
standards apply when a program participant is receiving financial assistance 
and moving into a new (different) unit or remaining in a current unit.  
Inspections must be conducted upon initial occupancy and then on an annual 
basis for the term of ESG assistance. 
The habitability standards are different from the Housing Quality Standards 
(HQS) used for other HUD programs.  Because the HQS criteria are more 
stringent than the habitability standards, a grantee could use either standard.  
In contrast to HQS inspections, the habitability standards do not require a 
certified inspector.  As such, ESG program staff could conduct the inspections, 
using a form such as this one to document compliance.  
 
Instructions: Mark each statement as ‘A’ for approved or ‘D’ for deficient.  The property must meet all 
standards in order to be approved.  A copy of this checklist should be placed in the client file.  
Approved 
or  Element 
Deficient 
  1. Structure and materials: The structures must be structurally sound so as not to pose 
any threat to the health and safety of the occupants and so as to protect the 
residents from hazards. 
  2. Access: The housing must be accessible and capable of being utilized without 
unauthorized use of other private properties.  Structures must provide alternate 
means of egress in case of fire. 
  3. Space and security: Each resident must be afforded adequate space and security for 
themselves and their belongings.  Each resident must be provided with an 
acceptable place to sleep. 
  4. Interior air quality: Every room or space must be provided with natural or 
mechanical ventilation.  Structures must be free of pollutants in the air at levels that 
threaten the health of residents. 
  5. Water Supply: The water supply must be free from contamination. 
  6. Sanitary Facilities: Residents must have access to sufficient sanitary facilities that 
are in proper operating condition, may be used in privacy, and are adequate for 
personal cleanliness and the disposal of human waste.  

 
 

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Form #: ESG-216
 
  7. Thermal environment: The housing must have adequate heating and/or cooling 
facilities in proper operating condition. 
  8. Illumination and electricity: The housing must have adequate natural or artificial 
illumination to permit normal indoor activities and to support the health and safety 
of residents.  Sufficient electrical sources must be provided to permit use of 
essential electrical appliances while assuring safety from fire. 
  9. Food preparation and refuse disposal: All food preparation areas must contain 
suitable space and equipment to store, prepare, and serve food in a sanitary 
manner.  
  10. Sanitary condition: The housing and any equipment must be maintained in sanitary 
condition. 
  11. Fire safety: Both conditions below must be met to meet this standard. 
  a. Each unit must include at least one battery‐operated or hard‐wired 
smoke detector, in proper working condition, on each occupied level of 
the unit.  Smoke detectors must be located, to the extent practicable, in 
a hallway adjacent to a bedroom.  If the unit is occupied by hearing‐
impaired persons, smoke detectors must have an alarm system 
designed for hearing‐impaired persons in each bedroom occupied by a 
hearing‐impaired person. 
  b. The public areas of all housing must be equipped with a sufficient 
number, but not less than one for each area, of battery‐operated or 
hard‐wired smoke detectors.  Public areas include, but are not limited 
to, laundry rooms, day care centers, hallways, stairwells, and other 
common areas. 
(Source: U.S. Department of Housing and Urban Development, Docket No. FR‐5307‐N‐01,) 

CERTIFICATION STATEMENT 
I certify that I am not a HUD certified inspector and I have evaluated the property located at the address 
below to the best of my ability and find the following:   
  Property meets all of the above standards.    
  Property does not meet all of the above standards. 
Therefore, I make the following determination:    
  Property is approved. 
  Property is not approved. 

Case Name:              
Street Address:             
Apartment:              City:              State:              Zip:             
Evaluator’s Signature:                                                                 Date:             
Please Print. Name:        Terushia
      Jackson
  Exec. Dir. Initial: ____________________ 
 

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Emergency Solutions Grant 2012

Lead Screening Worksheet

About this Tool

The Lead Screening Worksheet is intended to guide grantees through the lead-based paint
inspection process to ensure compliance with the rule. ESG staff can use this worksheet to
document any exemptions that may apply, whether any potential hazards have been identified,
and if safe work practices and clearance are required and used. A copy of the completed
worksheet along with any additional documentation should be kept in each program
participant’s case file. Please see the ESG Lead-Based Paint Requirements Summary for
additional information.

INSTRUCTIONS
To prevent lead-poisoning in young children, ESG grantees must comply with the Lead-Based Paint
Poisoning Prevention Act of 1973 and its applicable regulations found at 24 CFR 35, Parts A, B, M, and R.
Under certain circumstances, a visual assessment of the unit is not required. This screening worksheet
will help program staff determine whether a unit is subject to a visual assessment, and if so, how to
proceed. A copy of the completed worksheet along with any related documentation should be kept in
each program participant’s file.
Note: ALL pre-1978 properties are subject to the disclosure requirements outlined in 24 CFR 35, Part A,
regardless of whether they are exempt from the visual assessment requirements.

BASIC INFORMATION
Name of Participant Lori Zeth

Address 1424 Overland Pass, Unit Number L401

City Claysburg

State PA Zip 16624

ESG Program Staff Terushia Jackson

PART 1: DETERMINE WHETHER THE UNIT IS SUBJECT TO A VISUAL ASSESSMENT

If the answer to one or both of the following questions is ‘no,’ a visual assessment is not triggered for
this unit and no further action is required at this time. Place this screening worksheet and related
documentation in the program participant’s file.
If the answer to both of these questions is ‘yes,’ then a visual assessment is triggered for this unit and
program staff should continue to Part 2.
1. Was the leased property constructed before 1978?
Yes No
2. Will a child under the age of six be living in the unit occupied by the household receiving ESG
assistance?
Yes No

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Emergency Solutions Grant 2012

PART 2: DOCUMENT ADDITIONAL EXEMPTIONS

If the answer to any of the following questions is ‘yes,’ the property is exempt from the visual
assessment requirement and no further action is needed at this point. Place this screening sheet and
supporting documentation for each exemption in the program participant’s file.
If the answer to all of these questions is ‘no,’ then continue to Part 3 to determine whether deteriorated
paint is present.
1. Is it a zero-bedroom or SRO-sized unit?
Yes No
2. Has X-ray or laboratory testing of all painted surfaces by certified personnel been conducted in
accordance with HUD regulations and the unit is officially certified to not contain lead-based
paint?
Yes No
3. Has this property had all lead-based paint identified and removed in accordance with HUD
regulations?
Yes No
4. Is the client receiving Federal assistance from another program, where the unit has already
undergone (and passed) a visual assessment within the past 12 months (e.g., if the client has a
Section 8 voucher and is receiving ESG assistance for a security deposit or arrears)?
Yes (Obtain documentation for the case file.)
No
5. Does the property meet any of the other exemptions described in 24 CFR Part 35.115(a).
Yes No
Please describe the exemption and provide appropriate documentation of the exemption.

PART 3: DETERMINE THE PRESENCE OF DETERIORATED PAINT

To determine whether there are any identified problems with paint surfaces, program staff should
conduct a visual assessment prior to providing ESG financial assistance to the unit as outlined in the
following training on HUD’s website at:
http://www.hud.gov/offices/lead/training/visualassessment/h00101.htm.
If no problems with paint surfaces are identified during the visual assessment, then no further action is
required at this time. Place this screening sheet and certification form (Attachment A) in the program
participant’s file.
If any problems with paint surfaces are identified during the visual assessment, then continue to Part 4
to determine whether safe work practices and clearance are required.

1. Has a visual assessment of the unit been conducted?

Yes No

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Emergency Solutions Grant 2012
2. Were any problems with paint surfaces identified in the unit during the visual assessment?
Yes No (Complete Attachment A – Lead-Based Paint Visual Assessment
Certification Form)

PART 4: DOCUMENT THE LEVEL OF IDENTIFIED PROBLEMS

All deteriorated paint identified during the visual assessment must be repaired prior to clearing the unit
for assistance. However, if the area of paint to be stabilized exceeds the de minimus levels (defined
below), the use of lead safe work practices and clearance is required.
If deteriorating paint exists but the area of paint to be stabilized does not exceed these levels, then the
paint must be repaired prior to clearing the unit for assistance, but safe work practices and clearance
are not required.
1. Does the area of paint to be stabilized exceed any of the de minimus levels below?
• 20 square feet on exterior surfaces Yes No
• 2 square feet in any one interior room or space Yes No
• 10 percent of the total surface area on an interior or exterior component with a small
surface area, like window sills, baseboards, and trim Yes No
If any of the above are ‘yes,’ then safe work practices and clearance are required prior to clearing the
unit for assistance.

PART 5: CONFIRM ALL IDENTIFIED DETERIORATED PAINT HAS BEEN STABILIZED

Program staff should work with property owners/managers to ensure that all deteriorated paint
identified during the visual assessment has been stabilized. If the area of paint to be stabilized does not
exceed the de minimus level, safe work practices and a clearance exam are not required (though safe
work practices are always recommended). In these cases, the ESG program staff should confirm that the
identified deteriorated paint has been repaired by conducting a follow-up assessment.
If the area of paint to be stabilized exceeds the de minimus level, program staff should ensure that the
clearance inspection is conducted by an independent certified lead professional. A certified lead
professional may go by various titles, including a certified paint inspector, risk assessor, or
sampling/clearance technician. Note, the clearance inspection cannot be conducted by the same firm
that is repairing the deteriorated paint.
1. Has a follow-up visual assessment of the unit been conducted?
Yes No
2. Have all identified problems with the paint surfaces been repaired?
Yes No

3. Were all identified problems with paint surfaces repaired using safe work practices?
Yes No
Not Applicable – The area of paint to be stabilized did not exceed the de minimus levels.

continued…

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Emergency Solutions Grant 2012
4. Was a clearance exam conducted by an independent, certified lead professional?
Yes No
Not Applicable – The area of paint to be stabilized did not exceed the de minimus levels.
5. Did the unit pass the clearance exam?
Yes No
Not Applicable – The area of paint to be stabilized did not exceed the de minimus levels.
Note: A copy of the clearance report should be placed in the program participant’s file.

ATTACHMENT 1: LEAD-BASED PAINT VISUAL ASSESSMENT CERTIFICATION TEMPLATE

Terushia Jackson
I, _________________________, certify the following:
• I have completed HUD’s online visual assessment training and am a HUD-certified visual
assessor.
• 1424 Overland Pass, Claysburg, PA 16625 Unit L401
I conducted a visual assessment at __________________________________________ on
_________________________________________________________________
3/9/21

• No problems with paint surfaces were identified in the unit or in the building’s common areas.

____________________________________
(Signature)
____________________________________
Mar 09 2021

(Date)

Lori Zeth
Client Name: ________________________
Case Number: _______________________

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Emergency Solutions Grant 2013

ESG Lead-Based Paint Property Owner Certification Form

About this Tool
The ESG Lead-Based Paint Property Owner Certification Form is a tool program staff can use to have
property owners/managers certify that all paint stabilization activities have been completed in accordance
with guidelines when formal clearance is not required (or as additional documentation when formal
clearance is required). A copy of the completed form along with any additional documentation (i.e., a
copy of the clearance report) should be kept in each program participant’s file.

INSTRUCTIONS
To prevent lead-poisoning in young children, the ESG program must comply with the Lead-Based Paint Poisoning Prevention
Act of 1973 and its applicable regulations found at 24 CFR 35, Parts A, B, M, and R. If a visual assessment reveals problems
with paint surfaces, property owners/managers must repair all identified problems with paint surfaces in accordance with
the guidelines of 24 CFR 35, Parts A, B, M, and R, prior to a unit receiving ESG assistance. Property owners/managers
should complete this form to certify that all identified problems with paint surfaces have been repaired/stabilized in
accordance with the guidelines.
1. Have all identified problems with the paint surfaces been repaired?
Yes No
2. Have all identified problems with paint surfaces been repaired using safe work practices?
Yes No
Not Applicable – The area of paint to be stabilized did not exceed the de minimus levels.
3. Was a clearance exam conducted by an independent, certified lead professional?
Yes No
Not Applicable – The area of paint to be stabilized did not exceed the de minimus levels.
4. Did the unit pass the clearance exam?
Yes No
Not Applicable – The area of paint to be stabilized did not exceed the de minimus levels.

Name of Tenant Lori Zeth

Address 1424 Overland Pass

Unit Number L401

City Claysburg

State PA Zip 16625

Name of Property Owner/Manager

Property Owner/Manager Signature Date
Name ESG Program Staff Terushia Jackson

ESG Program Staff Signature Date

Mar 09 2021

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

: ad28d070a36
Simple Steps To Protect Your Family
From Lead Hazards
If you think your home has high
levels of lead:
Get your young children tested for lead, even if
they seem healthy.
Wash children’s hands, bottles, pacifiers, and toys
often.
Make sure children eat healthy, low-fat foods.
Get your home checked for lead hazards.
Regularly clean floors, window sills, and other
surfaces.
Wipe soil off shoes before entering house.
Talk to your landlord about fixing surfaces with
peeling or chipping paint.
Take precautions to avoid exposure to lead dust
when remodeling or renovating (call 1-800-424-
LEAD for guidelines).
Don’t use a belt-sander, propane torch, high
temperature heat gun, scraper, or sandpaper on
painted surfaces that may contain lead.
Don’t try to remove lead-based paint yourself.

Recycled/Recyclable
eversign
Printed Document
with Hash:
vegetable oil ad28d070a36f48db9eec14d06857c90f
based inks on recycled paper
(minimum 50% postconsumer) process chlorine free.
Protect
Your
Family
From
Lead In
Your
Home
United States
Environmental
Protection Agency

United States
Consumer Product
Safety Commission

United States
Department of Housing
and Urban Development

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Are You Planning To Buy, Rent, or Renovate
a Home Built Before 1978?

M
any houses and apartments built before 1978 have
paint that contains high levels of lead (called lead-
based paint). Lead from paint, chips, and dust can
pose serious health hazards if not taken care of properly.

OWNERS, BUYERS, and RENTERS are

encouraged to check for lead (see page 6)
before renting, buying or renovating pre-
1978 housing.

F
ederal law requires that individuals receive certain
information before renting, buying, or renovating
pre-1978 housing:

LANDLORDS have to disclose known infor-

mation on lead-based paint and lead-based
paint hazards before leases take effect.
Leases must include a disclosure about
lead-based paint.

SELLERS have to disclose known informa-

tion on lead-based paint and lead-based
paint hazards before selling a house. Sales
contracts must include a disclosure about
lead-based paint. Buyers have up to 10
days to check for lead.

RENOVATORS disturbing more than 2 square

feet of painted surfaces have to give you
this pamphlet before starting work.

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IMPORTANT!

Lead From Paint, Dust, and

Soil Can Be Dangerous If Not
Managed Properly
FACT: Lead exposure can harm young
children and babies even before they
are born.
FACT: Even children who seem healthy can
have high levels of lead in their bodies.
FACT: People can get lead in their bodies by
breathing or swallowing lead dust, or by
eating soil or paint chips containing
lead.
FACT: People have many options for reducing
lead hazards. In most cases, lead-based
paint that is in good condition is not a
hazard.
FACT: Removing lead-based paint improperly
can increase the danger to your family.

If you think your home might have lead

hazards, read this pamphlet to learn some
simple steps to protect your family.

1
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Lead Gets in the Body in Many Ways

People can get lead in their body if they:

Childhood
Breathe in lead dust (especially during
lead renovations that disturb painted
poisoning surfaces).
remains a Put their hands or other objects
major covered with lead dust in their mouths.
environmen- Eat paint chips or soil that contains
tal health lead.
problem in
the U.S. Lead is even more dangerous to children
under the age of 6:
At this age children’s brains and nervous
systems are more sensitive to the dam-
aging effects of lead.
Even children Children’s growing bodies absorb more
who appear lead.
healthy can Babies and young children often put
have danger- their hands and other objects in their
ous levels of mouths. These objects can have lead
lead in their dust on them.
bodies.
Lead is also dangerous to women of
childbearing age:
Women with a high lead level in their
system prior to pregnancy would expose
a fetus to lead through the placenta
during fetal development.

2
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Lead’s Effects
It is important to know that even exposure
to low levels of lead can severely harm
children.
In children, lead can cause:
Nervous system and kidney damage.
Learning disabilities, attention deficit Brain or Nerve Damage

disorder, and decreased intelligence. Hearing

Problems
Speech, language, and behavior
problems.
Poor muscle coordination.
Slowed
Decreased muscle and bone growth. Growth

Hearing damage.
While low-lead exposure is most
common, exposure to high levels of
lead can have devastating effects on
children, including seizures, uncon-
sciousness, and, in some cases, death.
Although children are especially
susceptible to lead exposure, lead
can be dangerous for adults too.
Digestive
In adults, lead can cause: Problems

Increased chance of illness during Reproductive

Problems
pregnancy. (Adults)

Harm to a fetus, including brain

damage or death. Lead affects
Fertility problems (in men and women). the body in
many ways.
High blood pressure.
Digestive problems.
Nerve disorders.
Memory and concentration problems.
Muscle and joint pain.

3
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Where Lead-Based Paint Is Found

Many homes built before 1978 have lead-

In general, based paint. The federal government
the older your banned lead-based paint from housing in
home, the 1978. Some states stopped its use even
more likely it earlier. Lead can be found:
has lead- In homes in the city, country, or suburbs.
based paint. In apartments, single-family homes, and
both private and public housing.
Inside and outside of the house.
In soil around a home. (Soil can pick up
lead from exterior paint or other sources
such as past use of leaded gas in cars.)

Checking Your Family for Lead

To reduce your child's exposure to lead,
Get your get your child checked, have your home
children and tested (especially if your home has paint
home tested in poor condition and was built before
if you think 1978), and fix any hazards you may have.
Children's blood lead levels tend to increase
your home rapidly from 6 to 12 months of age, and
has high lev- tend to peak at 18 to 24 months of age.
els of lead. Consult your doctor for advice on testing
your children. A simple blood test can
detect high levels of lead. Blood tests are
usually recommended for:
Children at ages 1 and 2.
Children or other family members who
have been exposed to high levels of lead.
Children who should be tested under
your state or local health screening plan.
Your doctor can explain what the test results
mean and if more testing will be needed.

4
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Identifying Lead Hazards

Lead-based paint is usually not a hazard if

it is in good condition, and it is not on an Lead from
impact or friction surface, like a window. It paint chips,
is defined by the federal government as which you
paint with lead levels greater than or equal
to 1.0 milligram per square centimeter, or can see, and
more than 0.5% by weight. lead dust,
Deteriorating lead-based paint (peeling, which you
chipping, chalking, cracking or damaged) can’t always
is a hazard and needs immediate attention. see, can both
It may also be a hazard when found on sur- be serious
faces that children can chew or that get a hazards.
lot of wear-and-tear, such as:
Windows and window sills.
Doors and door frames.
Stairs, railings, banisters, and porches.
Lead dust can form when lead-based paint is scraped, sanded, or
heated. Dust also forms when painted surfaces bump or rub togeth-
er. Lead chips and dust can get on surfaces and objects that people
touch. Settled lead dust can re-enter the air when people vacuum,
sweep, or walk through it. The following two federal standards have
been set for lead hazards in dust:
40 micrograms per square foot (µg/ft2) and higher for floors,
including carpeted floors.
250 µg/ft2 and higher for interior window sills.
Lead in soil can be a hazard when children play in bare soil or
when people bring soil into the house on their shoes. The following
two federal standards have been set for lead hazards in residential
soil:
400 parts per million (ppm) and higher in play areas of bare soil.
1,200 ppm (average) and higher in bare soil in the remainder of
the yard.
The only way to find out if paint, dust and soil lead hazards exist is
to test for them. The next page describes the most common meth-
ods used.
5
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Checking Your Home for Lead

You can get your home tested for lead in

Just knowing several different ways:
that a home A paint inspection tells you whether your
has lead- home has lead-based paint and where it
based paint is located. It won’t tell you whether or not
may not tell your home currently has lead hazards.
you if there A risk assessment tells you if your home
is a hazard. currently has any lead hazards from lead
in paint, dust, or soil. It also tells you what
actions to take to address any hazards.
A combination risk assessment and
inspection tells you if your home has
any lead hazards and if your home has
any lead-based paint, and where the
lead-based paint is located.
Hire a trained and certified testing profes-
sional who will use a range of reliable
methods when testing your home.
Visual inspection of paint condition
and location.
A portable x-ray fluorescence (XRF)
machine.
Lab tests of paint, dust, and soil
samples.
There are state and federal programs in
place to ensure that testing is done safely,
reliably, and effectively. Contact your state
or local agency (see bottom of page 11) for
more information, or call 1-800-424-LEAD
(5323) for a list of contacts in your area.
Home test kits for lead are available, but
may not always be accurate. Consumers
should not rely on these kits before doing
renovations or to assure safety.

6
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What You Can Do Now To Protect
Your Family

If you suspect that your house has lead

hazards, you can take some immediate
steps to reduce your family’s risk:
If you rent, notify your landlord of
peeling or chipping paint.
Clean up paint chips immediately.
Clean floors, window frames, window
sills, and other surfaces weekly. Use a
mop or sponge with warm water and a
general all-purpose cleaner or a cleaner
made specifically for lead. REMEMBER:
NEVER MIX AMMONIA AND BLEACH
PRODUCTS TOGETHER SINCE THEY
CAN FORM A DANGEROUS GAS.
Thoroughly rinse sponges and mop
heads after cleaning dirty or dusty
areas.
Wash children’s hands often, especial-
ly before they eat and before nap time
and bed time.
Keep play areas clean. Wash bottles,
pacifiers, toys, and stuffed animals
regularly.
Keep children from chewing window
sills or other painted surfaces.
Clean or remove shoes before
entering your home to avoid
tracking in lead from soil.
Make sure children eat
nutritious, low-fat meals high
in iron and calcium, such as
spinach and dairy products.
Children with good diets absorb
less lead.

7
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Reducing Lead Hazards In The Home

In addition to day-to-day cleaning and good

Removing nutrition:
lead You can temporarily reduce lead hazards
improperly by taking actions such as repairing dam-
can increase aged painted surfaces and planting grass
the hazard to to cover soil with high lead levels. These
actions (called “interim controls”) are not
your family permanent solutions and will need ongo-
by spreading ing attention.
even more To permanently remove lead hazards,
lead dust you should hire a certified lead “abate-
around the ment” contractor. Abatement (or perma-
house. nent hazard elimination) methods
include removing, sealing, or enclosing
Always use a lead-based paint with special materials.
professional who Just painting over the hazard with regular
is trained to paint is not permanent removal.
remove lead Always hire a person with special training
hazards safely.
for correcting lead problems—someone
who knows how to do this work safely and
has the proper equipment to clean up
thoroughly. Certified contractors will employ
qualified workers and follow strict safety
rules as set by their state or by the federal
government.
Once the work is completed, dust cleanup
activities must be repeated until testing
indicates that lead dust levels are below the
following:
40 micrograms per square foot (µg/ft2)
for floors, including carpeted floors;
250 µg/ft2 for interior windows sills; and
400 µg/ft2 for window troughs.
Call your state or local agency (see bottom
of page 11) for help in locating certified
professionals in your area and to see if
8 financial assistance is available.
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Remodeling or Renovating a Home With
Lead-Based Paint

Take precautions before your contractor or

you begin remodeling or renovating any-
thing that disturbs painted surfaces (such
as scraping off paint or tearing out walls):
Have the area tested for lead-based
paint.
Do not use a belt-sander, propane
torch, high temperature heat gun, dry
scraper, or dry sandpaper to remove
lead-based paint. These actions create
large amounts of lead dust and fumes.
Lead dust can remain in your home If not
long after the work is done.
conducted
Temporarily move your family (espe- properly,
cially children and pregnant women)
out of the apartment or house until
certain types
the work is done and the area is prop- of renova-
erly cleaned. If you can’t move your tions can
family, at least completely seal off the release lead
work area. from paint
Follow other safety measures to and dust into
reduce lead hazards. You can find out the air.
about other safety measures by calling
1-800-424-LEAD. Ask for the brochure
“Reducing Lead Hazards When
Remodeling Your Home.” This brochure
explains what to do before, during,
and after renovations.
If you have already completed renova-
tions or remodeling that could have
released lead-based paint or dust, get
your young children tested and follow
the steps outlined on page 7 of this
brochure.

9
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Other Sources of Lead

Drinking water. Your home might have

plumbing with lead or lead solder. Call
your local health department or water
supplier to find out about testing your
water. You cannot see, smell, or taste
lead, and boiling your water will not get
rid of lead. If you think your plumbing
might have lead in it:
• Use only cold water for drinking and
While paint, dust, cooking.
and soil are the
• Run water for 15 to 30 seconds
most common
sources of lead, before drinking it, especially if you
other lead have not used your water for a few
sources also exist. hours.
The job. If you work with lead, you
could bring it home on your hands or
clothes. Shower and change clothes
before coming home. Launder your work
clothes separately from the rest of your
family’s clothes.
Old painted toys and furniture.
Food and liquids stored in lead crystal
or lead-glazed pottery or porcelain.
Lead smelters or other industries that
release lead into the air.
Hobbies that use lead, such as making
pottery or stained glass, or refinishing
furniture.
Folk remedies that contain lead, such as
“greta” and “azarcon” used to treat an
upset stomach.

10
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For More Information

The National Lead Information Center

Call 1-800-424-LEAD (424-5323) to learn
how to protect children from lead poisoning
and for other information on lead hazards.
To access lead information via the web, visit
www.epa.gov/lead and
www.hud.gov/offices/lead/.
EPA’s Safe Drinking Water Hotline
Call 1-800-426-4791 for information about
lead in drinking water.
Consumer Product Safety
Commission (CPSC) Hotline
To request information on lead in
consumer products, or to report an
unsafe consumer product or a prod-
uct-related injury call 1-800-638-
2772, or visit CPSC's Web site at:
www.cpsc.gov.
Health and Environmental Agencies
Some cities, states, and tribes have
their own rules for lead-based paint
activities. Check with your local agency to
see which laws apply to you. Most agencies
can also provide information on finding a
lead abatement firm in your area, and on
possible sources of financial aid for reducing
lead hazards. Receive up-to-date address
and phone information for your local con-
tacts on the Internet at www.epa.gov/lead
or contact the National Lead Information
Center at 1-800-424-LEAD.

For the hearing impaired, call the Federal Information

Relay Service at 1-800-877-8339 to access any of
the phone numbers in this brochure.

11
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EPA Regional Offices
Your Regional EPA Office can provide further information regard-
ing regulations and lead protection programs.

EPA Regional Offices

Region 1 (Connecticut, Massachusetts, Region 6 (Arkansas, Louisiana, New
Maine, New Hampshire, Rhode Island, Mexico, Oklahoma, Texas)
Vermont) Regional Lead Contact
Regional Lead Contact U.S. EPA Region 6
U.S. EPA Region 1 1445 Ross Avenue, 12th Floor
Suite 1100 (CPT) Dallas, TX 75202-2733
One Congress Street (214) 665-7577
Boston, MA 02114-2023
1 (888) 372-7341

Region 7 (Iowa, Kansas, Missouri,

Region 2 (New Jersey, New York, Nebraska)
Puerto Rico, Virgin Islands)
Regional Lead Contact
Regional Lead Contact U.S. EPA Region 7
U.S. EPA Region 2 (ARTD-RALI)
2890 Woodbridge Avenue 901 N. 5th Street
Building 209, Mail Stop 225 Kansas City, KS 66101
Edison, NJ 08837-3679 (913) 551-7020
(732) 321-6671
Region 8 (Colorado, Montana, North
Region 3 (Delaware, Maryland, Dakota, South Dakota, Utah, Wyoming)
Pennsylvania, Virginia, Washington DC,
West Virginia) Regional Lead Contact
U.S. EPA Region 8
Regional Lead Contact 999 18th Street, Suite 500
U.S. EPA Region 3 (3WC33) Denver, CO 80202-2466
1650 Arch Street (303) 312-6021
Philadelphia, PA 19103
(215) 814-5000

Region 4 (Alabama, Florida, Georgia, Region 9 (Arizona, California, Hawaii,

Kentucky, Mississippi, North Carolina, Nevada)
South Carolina, Tennessee) Regional Lead Contact
Regional Lead Contact U.S. Region 9
U.S. EPA Region 4 75 Hawthorne Street
61 Forsyth Street, SW San Francisco, CA 94105
Atlanta, GA 30303 (415) 947-4164
(404) 562-8998
Region 10 (Alaska, Idaho, Oregon,
Region 5 (Illinois, Indiana, Michigan,
Washington)
Minnesota, Ohio, Wisconsin)
Regional Lead Contact
Regional Lead Contact
U.S. EPA Region 10
U.S. EPA Region 5 (DT-8J)
Toxics Section WCM-128
77 West Jackson Boulevard
1200 Sixth Avenue
Chicago, IL 60604-3666
Seattle, WA 98101-1128
(312) 886-6003
(206) 553-1985

12
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CPSC Regional Offices
Your Regional CPSC Office can provide further information regard-
ing regulations and consumer product safety.

Eastern Regional Center Western Regional Center

Consumer Product Safety Commission Consumer Product Safety Commission
201 Varick Street, Room 903 1301 Clay Street, Suite 610-N
New York, NY 10014 Oakland, CA 94612
(212) 620-4120 (510) 637-4050

Central Regional Center

Consumer Product Safety Commission
230 South Dearborn Street, Room 2944
Chicago, IL 60604
(312) 353-8260

HUD Lead Office

Please contact HUD's Office of Healthy Homes and Lead Hazard
Control for information on lead regulations, outreach efforts, and
lead hazard control and research grant programs.

U.S. Department of Housing and Urban Development

Office of Healthy Homes and Lead Hazard Control
451 Seventh Street, SW, P-3206
Washington, DC 20410
(202) 755-1785

This document is in the public domain. It may be reproduced by an individual or

organization without permission. Information provided in this booklet is based
upon current scientific and technical understanding of the issues presented and
is reflective of the jurisdictional boundaries established by the statutes governing
the co-authoring agencies. Following the advice given will not necessarily pro-
vide complete protection in all situations or against all health hazards that can
be caused by lead exposure.

U.S. EPA Washington DC 20460 EPA747-K-99-001

U.S. CPSC Washington DC 20207 June 2003
U.S. HUD Washington DC 20410
13
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Center for Community Action
Lead-Based Paint Packet Verification

I have received the lead-based paint infomration packet, “Protect Your Family From Lead Paint
in Your Home”. In addition, I have been verbally informed about the potential dangers of lead-
based paint and how to identify potential problem areas.

I now understand that any housing unit that I may obtain that was built prior to 1978 may have
lead issues. I also understand that any housing unit in which children 6 years old and younger
live in or regularly visit must pass a lead inspection before the unit can be occupied.

Mar 09 2021
___________________________________ __________________________

Client Signature Date

Mar 09 2021
___________________________________ __________________________

Staff Signature Date

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Section 4

HMIS Date: Financial Assistance Form

(complete when financial assistance has been paid)

Copy of Lease or Deed

(sample copy is provided; remove when actual lease is in place)

Copy of Eviction or Shut Off Notice

(sample copy is provided; remove when actual eviction is in place)

Rental Acknowledgement
(completed by landlord)

Landlord Agreement
(completed by landlord)

Copy of W-9

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Section 5
CLIENT FORMS

Release of Necessary Information

Budgeting Class Agreement

(completed with class dates and times)

Re-Enrollment Policy

Emergency Contact Release

(completed in case we can not contact consumer)

Sexual Harassment Policy

Termination Policy

Grievance Policy

Appeal Procedure

HMIS Client Consent

(additional members in household must be listed)

Housing Program Handbook

(given to ALL applicants)

Housing Program Handbook Acknowledgement

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CSBG INTAKE PACKET

CONSENT TO RELEASE INFORMATION

I AUTHORIZE AND GIVE MY CONSENT TO CENTER FOR COMMUNITY ACTION TO RELEASE AND RECEIVE MY CONFIDENTIAL
INFORMATION BETWEEN:

NAME DOB SOCIAL SECURITY NUMBER

Lori Zeth
11/1/83 170-64-4259

ADDRESS PHONE

223 Cherry St, Roaring Springs, PA 16673 814-660-9895

COUNTY BOARD OF ASSISTANCE (COA) HOUSING AUTHORITY EMPLOYER

SOCIAL SECURITY ADMINISTRATION (SSA) COMMUNITY ACTION CAREERLINK

OFFICE OF VOC. REHAB (OVR) UTILITY CO. LITERACY COUNCIL

VETERANS ADMINISTRATION CHILDREN AND YOUTH SERVICES (CYS) OTHER

BEHAVIORAL HEALTH DRUG AND ALCOHOL OTHER

PROBATION/PAROLE LANDLORD OTHER

THE INFORMATION TO BE RELEASED/RECEIVED IS LIMITED TO THE FOLLOWING ITEMS FOR THE DATES

VERIFICATION OF BENEFITS VERIFICATION OF INCOME VERIFICATION OF DISABILITY STATUS

COORDINATION SERVICES VERIFICATION OF NOTICES/HOUSING COSTS LEGAL STATUS

HOUSING STATUS COMMUNITY SUPPORTS REP-PAYEE

SCHEDULING APPOINTMENTS REFERRAL EDUCATION PURPOSES HOUSING

CASE MANAGEMENT AVAILABLE SERVICES OTHER

OTHER OTHER

I VOLUNTARILY AUTHORIZE AND REQUEST DISCLOSURE OF CONFIDENTIAL INFORMATION INCLUDING WRITTEN/PAPER,

VERBAL/ORAL, AND ELECTRONIC INTERCHANGE.

I AGREE THAT INFORMATION I HAVE GIVEN IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT
PROVIDING FALSE INFORMATION NOW OR AT ANY LATER DATE WILL BE GROUND FOR IMMEDIATE TERMINATION FROM AGENCY
SERVICES.

I UNDERSTAND THAT THIS AUTHORIZATION IS VOLUNTARY AND THAT IF I REFUSE TO SIGN THIS AUTHORIZATION, I WILL NOT BE
REFUSED SERVICES.

I UNDERSTAND AND AGREE THAT I SHALL RELEASE CENTER FOR COMMUNITY ACTION FROM ANY LIABILITY OR DAMAGE
SUFFERED FROM SERVICES REQUESTED BY ME.

Center for Community Action 195 Drive In Ln Everett, PA 15537 814-623-9129

CCA is an equal opportunity employer and provider.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CSBG INTAKE PACKET

I UNDERSTAND THAT I HAVE NO OBLIGATION WHATSOEVER TO DISCLOSE ANY INFORMATION FROM MY INFORMATION
RECORDS. I ALSO UNDERSTAND THAT ONCE RELEASED, THIS INFORMATION MY NOT BE PROTECTED BY CONFIDENTIALITY OR
NON-DISCLOSURE LAWS. THE INFORMATION COULD POTENTIALLY BE USED AGAINST ME BY THE AGENCY/PERSON TO WHICH IT
IS RELEASED.

I UNDERSTAND THAT I MAY REVOKE THIS CONSENT AT ANY TIME BY NOTIFYING THE EXECUTIVE DIRECTOR IN WRITING, AND/OR
SPECIFYING AN EVENT OR CONDITION UPON WHICH THIS CONSENT WILL EXPIRE WITHOUT REVOCATION.

I UNDERSTAND THAT INFORMATION REGARDING DRUG AND/OR ALCOHOL TREATMENT IS PROTECTED BY FEDERAL LAW ,
FEDERAL REGULATIONS (42 CFR PART 2) PROHIBITS ANY FURTHER DISCLOSURE, UNLESS FURTHER DISCLOSURE IS EXPRESSLY
PERMITTED BY THE WRITTEN CONSENT OF THE PERSON TO WHOM IT PERTAINS, OR AS OTHER IS PERMITTED BY SUCH
REGULATIONS.

I HAVE READ AND UNDERSTAND ITS CONTENTS.

CLIENT SIGNATURE DATE

Mar 09 2021

CASE MANAGER SIGNATURE DATE

Mar 09 2021

COPY PROVIDED TO CLIENT ON

3/9/21

Center for Community Action 195 Drive In Ln Everett, PA 15537 814-623-9129

CCA is an equal opportunity employer and provider.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

BEDFORD COUNTY SHARED RELEASE FORM
AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION

Lori Zeth
Date ____________
3/9/21 Client/Consumer Name_________________________________

11/1/83 4259
Date of Birth _________________________________ SS# (last 4 digits) ___________________

I authorize and give my consent to (Lead Agency – check one)

Center for Community Action
Huntingdon-Bedford-Fulton Area Agency on Aging
Other: ______________________________________________
Other: ______________________________________________
Other: ______________________________________________

Authorized person from Lead Agency:

Terushia Jackson Housing Intake Specialist
Name/Title_____________________________________________________________
[email protected]
Email Address________________________________ Phone # _____________________
814-623-9129

Fax # _______________________________________
814-623-1444

to release and/or receive my confidential information between the above-named agency and any of the
secondary agencies identified below:
Center for Community Action
Huntingdon-Bedford-Fulton Area Agency on Aging
Bedford-Somerset Developmental and Behavioral Health Services
Other: ______________________________________________
Other: ______________________________________________
Other: ______________________________________________

Authorized person/s from secondary agency or agencies:

Terushia Jackson
Name/Title_____________________________________________________________
[email protected]
Email Address________________________________ Phone # _____________________
Fax # _______________________________________

Terushia Jackson
Name/Title_____________________________________________________________
[email protected]
Email Address________________________________ Phone # _____________________
Fax # _______________________________________

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

The information itemized below to be released/received for the purpose(s) itemized below is limited to the dates
from ______________ to ________________.

I voluntarily authorize and request disclosure of confidential information including written/paper, verbal/oral, and
electronic interchange. I understand that information is needed for the purpose of:
Coordination of care, which may include case management, scheduling appointments, or referrals
Housing location or leasing
Employment search or placement
Educational purposes
Legal assistance
Other: _____________________________________________________________________
Other: _____________________________________________________________________

The specific information to be released/received is limited to the following items:

Treatment history
Diagnoses or medical records
Rental history
Financial information
Employment information
Educational information
Legal charges/sentencing/terms of probation or parole
Drug, alcohol, or other substance abuse records
Other: _____________________________________________________________________
Other: _____________________________________________________________________

• I understand that I have the right to revoke this authorization at any time by notice in writing to the above
requesting agency. I understand the revocation will not apply to information already released in response to
this authorization. Unless otherwise revoked, this authorization is valid for one year from the date it is signed.
• I understand that this authorization is voluntary and that if I refuse to sign this authorization, I will not be
refused services for that reason from the requesting agency.
• I understand that any disclosure of information has the potential for an unauthorized re-disclosure and that the
re-disclosed information may not be protected by governmental privacy regulations.
• I understand that I may inspect or obtain a copy of the information to be used or disclosed.
• I understand that information regarding drug and/or alcohol treatment is protected by federal law. Federal
regulations (42 CFR Part 2) prohibits any further disclosure, unless further disclosure is expressly permitted by
the written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general
authorization for release of medical or other information is not sufficient for this purpose.
• I have read and understand this statement.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Mar 09 2021 Mar 09 2021
______________________________________ ____________________________________

Client/Consumer signature Date Witness signature Date

_______________________________________ ____________________________________

Parent/Legal Representative signature Date Identify legal representative’s authority

The person named above, who is unable to provide a signature, freely gave a verbal consent to the release of

information requested. He/she had the request read to him/her and understands the nature of the release. He/She

also understands that this consent may be orally revoked at any time.
Terushia Jackson Mar 09 2021
______________________________________________________________________________

Witness printed name Witness signature Date

_______________________________________________________________________________

Witness printed name Witness signature Date

Terushia Jackson
3/9/21
Date sent: _______________ Person sending: _________________________

Copy of this form given to client/consumer

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CENTER FOR COMMUNITY ACTION AGENCY

HOUSING PROGRAM
BEGINNER’S BUDGETING CLASSES AGREEMENT

I acknowledge that I have received during the intake process, a beginner’s budgeting
class. I understand that additional classes will be available to me if I so chose to take these
classes. I understand that I do not have to participate in this service to continue to receive
services, but this is just an additional resource that is offer by the Center for Community
Action.

Your budget class is scheduled as follows:

3/9/21
_________________ ____________
Date Time

Mar 09 2021
______________________________________ ________________________
Client Signature Date

______________________________________ ________________________
Mar 09 2021

Housing Case Manager Signature Date

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CENTER FOR COMMUNITY ACTION AGENCY
HOUSING PROGRAM
RE-ENROLLMENT POLICY

Enrollment and assistance paid out varies by different grants that individuals/families may
be enrolled into. Below is a list of grants and the maximum amount of assistance that is
allowed by the federal and the state government. The information below is not a promised
amount of rental assistance to each individual/family, but just what is may be provided
during a certain time frame. Any questions regarding these amounts please consult your case
manager, or the Human Services Director.

Emergency Solutions Grant (ESG) - cannot exceed 24 months during any 3-year period.

Homeless Assistance Program (HAP)- cannot exceed $1,000.00 in a two-year time span
for individuals, and for families cannot exceed $1,500.00 in a two-year time span.

Continuum of Care (COC) – cannot exceed 24 months during any 3-year period.

By Signing this form, I understand the following above is the rental assistance that may be
available to myself/or my family.

__________________________________ _______________________
Mar 09 2021

Client Signature Date

__________________________________ _______________________
Mar 09 2021

Case Manager Signature Date

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CENTER FOR COMMUNITY ACTION AGENCY

HOUSING PROGRAM
EMERGENCY CONTACT AND TRANSPORTATION

Emergency Contact Release

In case of an emergency or if I am unable to be contacted, I request the Housing Case

Manager to contact:

Name Address Telephone

Jerome DeLain Summerville South Carolina 843-813-7533
1
Karri Dively 207 France Street claysburg PA 16625 203-209-3069
2

I request the above persons be contacted in the order listed if I am unable to make a decision
that is necessary due to being unavailable.
Mar 09 2021

Name Date

Release/Hold Harmless

I also agree that the Housing Case Manager and any or all of their agents are in no way
responsible for vandalism, damage, loss or theft of my personal property that is stored,
transported or on their premises.

I also release the Housing Case Managers and any or all of their agents from all claims,
demands, suits and causes of action. I agree to hold them harmless and indemnify them
from such claims etc., relating to providing transportation and other services.
Mar 09 2021

Name Date

Mar 09 2021

Case Manager Date

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CSBG INTAKE PACKET

SEXUAL HARRASSMENT POLICY

CENTER FOR COMMUNITY ACTION IS COMMITTED TO PROVIDING AN ENVIRONMENT THAT IS FREE FROM ALL FORMS OF
DISCRIMINATION AND CONDUCT THAT CAN BE CONSIDERED HARASSING, COERCIVE, OR DISRUPTIVE, INCLUDING SEXUAL
HARASSMENT. ACTIONS, WORDS, JOKES OR COMMENTS BASED ON AN INDIVIDUAL’S SEX, RACE, COLOR, NATIONAL ORIGIN,
AGE, RELIGION, DISABILITY, SEXUAL ORIENTATION OR ANY OTHER LEGALLY PROTECTED CHARACTERISTIC WILL NOT BE
TOLERATED.

SEXUAL HARASSMENT IS DEFINED AS UNWANTED SEXUAL ADVANCES OR VISUAL, VERBAL OR PHYSICAL CONDUCT OF A SEXUAL
NATURE. THIS DEFINITION INCLUDES MANY FORMS OF OFFENSIVE BEHAVIOR AND INCLUDES GENDER-BASED HARASSMENT OF
A PERSON OF THE SAME SEX AS THE HARASSER. THE FOLLOWING IS A PARTIAL LIST OF SEXUAL HARASSMENT EXAMPLES:

1) UNWANTED SEXUAL ADVANCES

2) OFFERING EMPLOYMENT BENEFITS IN EXCHANGE FOR SEXUAL FAVORS
3) MAKING OR THREATENING REPRISALS AFTER A NEGATIVE RESPONSE TO SEXUAL ADVANCES
4) VISUAL CONDUCT THAT INCLUDES LEERING, MAKING SEXUAL GESTURES OR DISPLAYING OF SEXUALLY SUGGESTIVE OBJECTS
OR PICTURES, CARTOONS OR POSTERS
5) VERBAL CONDUCT INCLUDING MAKING OR USING DEROGATORY COMMENTS, EPITHETS, SLURS OR JOKES
6) VERBAL SEXUAL ADVANCES OR PROPOSITIONS
7) VERBAL ABUSE OF A SEXUAL NATURE, GRAPHIC VERBAL COMMENTARIES ABOUT AN INDIVIDUAL’S BODY, SEXUALLY
DEGRADING WORDS USED TO DESCRIBE AN INDIVIDUAL OR SUGGESTIVE OR OBSCENE LETTERS, NOTES OR INVITATIONS
8) PHYSICAL CONDUCT THAT INCLUDES TOUCHING, ASSAULTING OR IMPEDING OR BLOCKING MOVEMENTS

UNWELCOME SEXUAL ADVANCES (EITHER VERBAL OR PHYSICAL), REQUEST FOR SEXUAL FAVORS AND OTHER VERBAL OR
PHYSICAL CONDUCT OF A SEXUAL NATURE CONSTITUTES SEXUAL HARASSMENT WHEN:

1) SUBMISSION TO SUCH CONDUCT IS MADE EITHER EXPLICITLY OR IMPLICITLY A TERM OR CONDITION OF EMPLOYMENT OR
PARTICIPATION IN AN AGENCY PROGRAM
2) SUBMISSION OR REJECTION OF THE CONDUCT IS USED AS A BASIS FOR MAKING EMPLOYMENT OR PROGRAM
PARTICIPATION DECISIONS; OR
3) THE CONDUCT HAS THE PURPOSE OR EFFECT OF INTERFERING WITH WORK OR PROGRAM PERFORMANCE OR CREATING AN
INTIMIDATING, HOSTILE OR OFFENSIVE WORK ENVIRONMENT.

IF YOU EXPERIENCE OR WITNESS SEXUAL OR OTHER UNLAWFUL HARASSMENT AS A CLIENT OF THIS AGENCY, REPORT IT
IMMEDIATELY TO YOUR CASE MANAGER. IF THE CASE MANAGER IS UNAVAILABLE OR YOU BELIEVE IT WOULD BE INAPPROPRIATE
TO CONTACT THAT PERSON, YOU SHOULD IMMEDIATELY CONTACT THE EXECUTIVE DIRECTOR, OR ANY OTHER MEMBER OF THE
AGENCY’S MANAGEMENT STAFF. YOU CAN RAISE CONCERNS AND MAKE REPORTS WITHOUT FEAR OF REPRISAL OR
RETALIATION.

ALL ALLEGATIONS OF SEXUAL HARASSMENT WILL BE QUICKLY AND DISCREETLY INVESTIGATED. TO THE EXTENT POSSIBLE, YOUR
CONFIDENTIALITY AND THAT OF ANY WITNESSES AND THE ALLEGED HARASSER WILL BE PROTECTED AGAINST UNNECESSARY
DISCLOSURE. WHEN THE INVESTIGATION IS COMPLETED, YOU WILL BE INFORMED OF THE OUTCOME OF THE INVESTIGATION.

YOUR SIGNATURE BELOW SIGNIFIES THAT YOU HAVE READ THIS POLICY AND UNDERSTAND YOUR RIGHTS REGARDING SEXUAL
HARASSMENT.

CLIENT SIGNATURE DATE

Mar 09 2021

Center for Community Action 195 Drive In Ln Everett, PA 15537 814-623-9129

CCA is an equal opportunity employer and provider.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CSBG INTAKE PACKET

TERMINATION POLICY

HOW WILL I KNOW IF I HAVE BEEN DETERMINED ELIGIBLE?

1) YOU WILL BE GIVEN A NOTICE OF ELIGIBILITY OR INELIGIBILITY FOR HOMELESS ASSISTANCE.

2) IF YOU HAVE BEEN DETERMINED INELIGIBLE; YOUR NOTICE WILL SPECIFY THE REASON(S) FOR INELIGIBILITY.
3) IF YOU HAVE BEEN DETERMINED INELIGIBLE FOR REASON OF INCOMPLETE DOCUMENTATION; YOU WILL BE GIVEN THREE (3)
DAYS TO PRODUCE ALL MISSING DOCUMENTATION OR YOU WILL BE INELIGIBLE, AND YOUR FILE WILL BE CLOSED.

REASONS FOR TERMINATION FROM THE HOMELESS PROGRAM

1) THREATENING CENTER FOR COMMUNITY ACTION STAFF AND/OR THE STAFF OF ANY OTHER AGENCIES FROM WHICH YOU
ARE RECEIVING SERVICES.
2) PURPOSEFUL DAMAGE TO PROPERTY BELONGING TO AGENCY OR CASE MANAGERS.
3) UNLAWFUL ACTIONS ON CENTER FOR COMMUNITY ACTION PROPERTY.
4) BRINGING ANY WEAPONS ONTO AGENCY PROPERTY.
5) REFUSAL TO REPORT CHANGES IN FAMILY DYNAMIC AND/OR INCOME.
6) IF WE DETERMINE THAT YOU WILLFULLY PROVIDED FALSE INFORMATION ON YOUR APPLICATION TO GAIN ENROLLMENT
INTO OUR HOUSING PROGRAM.
7) IT IS THE RESPONSIBILITY OF THE CLIENT TO MAKE SURE THAT HE/SHE IS IN MEETING WITH THE CASE MANAGER MONTHLY,
AS ACCORDING TO HUD GUIDELINES. NON-COMPLIANCE WITH THIS WILL RESULT IN TERMINATION.

A LETTER WILL BE MAILED TO THE PARTICIPANT UPON TERMINATION CLEARLY STATING THE REASON FOR TERMINATION. CLIENT
CAN THEN PROVIDE WRITTEN/ORAL STATEMENT OF REASON WHY TERMINATION SHOULD NOT TAKE PLACE. REVIEWAL WILL BE
MADE, AND A FINAL DECISION WILL BE MADE. AGENCY WILL PROVIDE WRITTEN NOTICE OF FINAL DECISION.

THE HOUSING CASE MANAGERS STRIVE TO MAKE THIS A SAFE AND POSITIVE TIME IN YOUR LIFE.

Center for Community Action 195 Drive In Ln Everett, PA 15537 814-623-9129

CCA is an equal opportunity employer and provider.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CSBG INTAKE PACKET

GRIEVANCE POLICY

IN THE DAY-TO-DAY OPERATIONS OF OUR PROGRAMS, EVEN WITH THE BEST OF INTENTIONS, SOME CLIENTS WILL BE
DISSATISFIED WITH THE SERVICE(S) WE PROVIDE. IN AN EFFORT TO TREAT EACH CLIENT FAIRLY IN ALL RESPECTS, CLIENTS WHO
FEEL THEY HAVE BEEN SUBJECTED TO UNFAIR TREATMENT OR POOR WORK QUALITY SHALL HAVE THE RIGHT TO APPEAL.

1) A VERBAL OR WRITTEN COMPLAINT CAN BE FILED WITH THE PROGRAM MANAGER. THE PROGRAM MANAGER MUST REPLY
TO THE COMPLAINT, IN WRITING, WITHIN TEN (10) WORKING DAYS.
2) IF THE CLIENT IS NOT SATISFIED, THEY MAY FILE A WRITTEN COMPLAINT WITH THE CENTER FOR COMMUNITY ACTION’S
EXECUTIVE DIRECTOR WITHIN TEN (10) WORKING DAYS.
3) THE EXECUTIVE DIRECTOR SHALL RESPOND TO THE WRITTEN COMPLAINT WITHIN TEN (10) WORKING DAYS. IF THE CLIENT
IS NOT SATISFIED WITH THE EXECUTIVE DIRECTOR’S DECISION, THEY MAY APPEAL TO THE FUNDING SOURCE.

CLIENT SIGNATURE DATE

Mar 09 2021

CASE MANAGER SIGNATURE DATE

Mar 09 2021

Center for Community Action 195 Drive In Ln Everett, PA 15537 814-623-9129

CCA is an equal opportunity employer and provider.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

PA HMIS Collaborative Client Consent
Release of Information via PA HMIS

The Pennsylvania Homeless Management Information System (“PA HMIS”) serves the Pennsylvania Continuums of Care
Collaborative, a group of agencies (“PA HMIS Participating Agencies”) working together to provide services to individuals
and families in Pennsylvania who are homeless or at risk of becoming homeless. In an effort to end homelessness, PA
HMIS allows the Commonwealth of Pennsylvania and PA HMIS Participating Agencies to use this system to efficiently
collaborate, identify, coordinate, and evaluate individual services needed. The PA HMIS is also used to produce non-
identifying, aggregate reports that can be used to track program performance which is necessary to receive program
funding from the federal government, identify unfilled service needs, and plan for new service provision.

This process is beneficial to improving your case management and received services, as well as assisting PA HMIS
Participating Agencies to locate multiple housing or service options. Additionally, sharing information between PA HMIS
Participating Agencies can reduce the number of times you are asked for repeated information. By consenting to share
this information with participating agencies, you will allow PA HMIS to provide better coordination between PA HMIS
Participating Agencies in an effort for you to obtain and maintain permanent housing.

Information collected in the PA HMIS database is protected in compliance with the standards set forth in the Health
Insurance Portability and Accountability Act (HIPAA). Every person and agency that is authorized to read or enter
information into the database has signed an agreement to maintain the security and confidentiality of your information.
Any person or agency that is found to violate their agreement may have their access rights terminated and may be
subject to further penalties including legal action.

I UNDERSTAND THAT:

 In an effort to end homelessness and to better serve me and/or my family, the PA HMIS Participating Agency
identified at the bottom of this form will collect and may share my identifying information with other PA HMIS
Participating Agencies via PA HMIS.

 The intention and purpose of collecting and sharing my information is to help PA HMIS Participating Agencies
better understand and assist my/our needs, and to produce non-identifying, aggregate reports to the federal
government that can be used to track the program performance of these agencies.

 The PA HMIS participating agencies have signed agreements and are bound to implement policies to maintain
my information in a secure and confidential manner, as mandated by Federal and State laws.

 The release of my information does not guarantee that I will receive assistance. Alternatively, refusing to
release my information will not affect my opportunity to receive assistance.

 This authorization will remain in effect unless I revoke it in writing. I may revoke authorization at any time by
returning to the PA HMIS Participating Agency identified at the bottom of this form and signing a new consent
form using the “I do not agree” option. If I revoke my authorization, all information about me already in the
database will remain to retain usage history; however, it will be inactive and not updated. I further understand
that any revocation of this consent will not affect the waiver of confidentiality as to information already
disclosed.
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PA HMIS Collaborative Client Consent
Release of Information via PA HMIS

 If I decline to release my information, it will be hidden from all other PA HMIS participating agencies, except in
the case of a referral. If I need to be referred to another agency for services, my information will be forwarded
to only that agency, regardless of my recorded data sharing preference.

Please choose an option:

✔ I agree to allow sharing of my information via the PA HMIS system with PA HMIS participating agencies.

I agree to allow sharing of my information via the PA HMIS system with PA HMIS participating agencies,
but wish to limit sharing of certain data elements (complete and attach the Release of Information
Supplement).

I do not agree to allow sharing of my information via the PA HMIS system with PA HMIS Participating
Agencies. I understand that if I need to be referred to another agency, only the data necessary to
complete the referral will be forwarded.

Lori Zeth Mar 09 2021

__________________________________ _______________________________ ____________
Client Name Client Signature Date
(Please print)

__________________________________ _______________________________ ____________

Guardian Name, if applicable Guardian Signature, if applicable Date
(Please print)

List Dependent(s) Name(s), if applicable

(Note: If dependents are not presenting for services at the same time as the guardian, or the guardian wishes to record different individual consent
responses, use a separate consent form for each dependent.)

____________________________________________________________________________________

_______________________________________________
PA HMIS Participating Agency Name
(Please print)
Terushia Jackson Mar 09 2021
__________________________________ ________________________________ ____________
Agency Personnel Agency Personnel Signature Date
(Please print)

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PA HMIS Collaborative Client Consent
Release of Information Supplement Form
Please use this form to collect the information that a client wishes to share if the partial/ limited option is selected on
the Client Consent – Release of Information (ROI) form. Place a check next to the information for which sharing is
permitted and attach to the ROI.

General Information  (All) Health Information  (All)

Name  Disabling Condition 

Alias  Physical Disability 
Date of Birth  Developmental Disability 
Place of Birth  Chronic Health Condition 
SSN  HIV/AIDS 
Mental Health 
Additional General Information  (All) Substance Abuse 
General Health 
Maiden Name  
Pregnancy Status
Mother’s Maiden Name 
State ID   (All)
Employment Information
Primary Language 
Veteran Status  Employment Status 
Housing Status  Hours Worked 
Employment Tenure 
Looking For Work 
Contact Information  (All)

Address  Education Information  (All)

Primary Phone  
Enrollment Status
Secondary Phone  
Vocational Training
Email Address  
Highest Level of Schooling
Degrees Earned 
 (All) School Name 
Physical Information
McKinney-Vento Act 
Height  School Type 
Eye Color  Last Date of Enrollment 
Ethnicity  Enrollment Problems 
Race 
Gender  Military History Information 
Income Information 
Benefit Information 
Services Received Information 

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CSBG INTAKE PACKET

APPEAL PROCEDURE

YOU ARE HEREBY NOTIFIED OF YOUR RIGHT TO APPEAL WHERE ANY ACTION(S) HAS/HAVE TAKEN PLACE BY THIS AGENCY WHICH
RESULTS IN 1) A DENIAL, REDUCTION, OR TERMINATION OF SERVICES OR 2) THE AGENCY FAILS TO ACT UPON A REQUEST FOR
SERVICE WITH REASONABLE PROMPTNESS.

THAT IN COMPLIANCE WITH TITLE VI OF THE CIVIL RIGHTS ACT OF 1964, SECTION 504 OF THE FEDERAL REHABILITATION ACT OF
1973; THE AGE DISCRIMINATION ACT OF 1975; AND THE PENNSYLVANIA HUMAN RELATIONS ACT OF 1955, AS AMENDED, AND
THE 16 PA CODE, CHAPTER 49 (CONTRACT COMPLIANCE REGULATIONS) INCLUDING:

1) THE AGENCY ALSO DOES NOT AND WILL NOT DISCRIMINATE AGAINST ANY
PERSON(S) BECAUSE OF RACE, RELIGION, CREED, ANCESTRY, AGE, NATIONAL
ORIGIN, AGE, AND/OR EMOTIONAL/PHYSICAL HANDICAPS WHEN
a) PROVIDING SERVICES OF EMPLOYMENT, OR IN ITS RELATIONSHIP
WITH OTHER PROVIDERS;
b) PROVIDING ACCESS TO SERVICES AND EMPLOYMENT FOR
HANDICAPPED INDIVIDUALS.
2) THE AGENCY WILL COMPLY WITH ALL REGULATIONS PROMULGATED TO
ENFORCE THE STATUTORY PROVISIONS AGAINST DISCRIMINATION.

YOU ARE FURTHER ADVISED THAT YOU HAVE A RIGHT TO BE REPRESENTED BY AN ATTORNEY OR A SPOKESPERSON OF
YOUR CHOICE AT AN APPEAL HEARING WITH THE DEPARTMENT OF PUBLIC WELFARE. THE ADDRESS AND TELEPHONE OF THE
COUNTY LEGAL SERVICES OFFICE, WHERE YOU CAN INQUIRE ABOUT LEGAL ASSISTANCE/FILE AN APPEAL IS:

MIDPENN LEGAL SERVICES, 232 EAST PITT STREET, BEDFORD PA 15522

(814) 623-6189

THE CLIENT SHALL BE INFORMED OF ACTION BEING TAKEN, THE REASON FOR THE ACTION, THE EFFECTIVE DATE OF THE
ACTION, THE AVAILABILITY OF THE APPEAL PROCESS AT THE COUNTY LEVEL. ALL DOCUMENTATION SHALL BE MAINTAINED IN
THE CLIENT’S FILE.

CLIENT SIGNATURE DATE

Mar 09 2021

CASE MANAGER SIGNATURE DATE

Mar 09 2021

Center for Community Action 195 Drive In Ln Everett, PA 15537 814-623-9129

CCA is an equal opportunity employer and provider.

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

CENTER FOR COUMMUNITYACTION

HOUSING PROGRAM HANDBOOK ACKNOWLEDGEMENT

The PA Landlord-Tenant Act gives you specific rights as a tenant. The Housing Case
Manager will provide you with a copy of the act at your request.

You have also been provided with a copy of the CCA Housing Handbook and you are
expected to comply with the rules and guidelines stated therein.

I acknowledge that I have received and gone over the housing handbook with my Case
Manager. I understand that I can obtain a copy of the Landlord Tenant Act upon request.
I have had the policy for not following rules and termination from Center for Community
Action’s Housing Program explained to me. I understand the procedure for following
these guidelines and the consequences for failure to comply.

Mar 09 2021

Client Signature Date

Mar 09 2021

Case Manager Signature Date

1
eversign Document Hash: ad28d070a36f48db9eec14d06857c90f
Section 6

_____ Exit Letter

Invoice

Copy of Check and letter

Tracking Form
(filled out for assurance follow up is completed in 30 and 60 days)

HMIS Date: Exit Form

Documented Checklist

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

TRACKING FORM

Lori Zeth
Participant Name

Telephone Number

Program

Status ( ) Eligible and payment made

( ) Not Eligible
Reason

( ) Waiting for Information

Still Needed

( ) Follow Up for information of not received in 1 week

Date

FOLLOW UP IN 30 DAYS ON
NOTES

FOLLOW UP IN 60 DAYS ON
NOTES

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f

Signatures

Date: Mar 09 2021

____________________ Signature: ____________________
Tiffany Jones

eversign Document Hash: ad28d070a36f48db9eec14d06857c90f