EMERGENCY SOLUTIONS GRANT (ESG)

Rapid Re-Housing Certification

MSHDA ESG Rapid Re-Housing Certification (09/2020) Page 1 of 1 Participant Information

Participant Name: HMIS #:

Instructions: This form is to be completed by ESG program staff to certify homelessness and participant eligibility for Rapid Re-Housing services. Check the housing status box applicable to the individual or family below and retain both this form and proper documentation to support the housing status in the participant file. Unless otherwise noted, the general order of priority for obtaining evidence is third-party documentation first, intake worker observations second, and certification by the individual or family seeking assistance third. General Eligibility

ESG funds may be used to provide housing relocation and stabilization services and short- and/or medium-term rental assistance as necessary to help a homeless individual or family move as quickly as possible into permanent housing and achieve stability in that housing. Rapid Re-Housing assistance may be provided to program participants who meet the criteria under paragraph (1) of the “homeless” definition in § 567.2, provided they have an annual income below 30% area median income. (§ 567.104).

Criteria for Rapid Re-Housing

Category 1: Literally Homeless

Place Not Meant for Human Habitation A public or private place not meant for, or ordinarily used as a regular sleeping accommodation for human beings, including street, sidewalk, car, park, abandoned building, bus station, airport, or camp ground.

• Documentation may include written certification by an outreach worker, recent HMIS record, or self- certification outlined in ESG Self-Certification.

Emergency Shelter A publicly or privately-owned emergency shelter designated to provide temporary living accommodations.

• Documentation may include written referral from previous shelter staff, recent HMIS record, or self- certification outlined in ESG Self-Certification.

Hotel or Motel paid for by a Charitable Organization or Federal, State, and Local Government Program

• Documentation may include written referral from charitable organization or government program, recent HMIS record, or self-certification outlined in ESG Self-Certification. Exiting an Institutional Care Facility (i.e. jail, substance abuse treatment facility, mental health treatment facility, hospital, or other similar facility); stay must be 90 days or less and resided in a shelter or place not meant for human habitation before entering the institution.

• Documentation may include discharge paperwork or written referral from institution, recent HMIS record, or self-certification outlined in ESG Self-Certification. Transitional Housing A project that is designed to provide housing and appropriate supportive services to homeless persons to facilitate movement to independent living.

• Documentation may include written referral from service provider, recent HMIS record, or self-certification outlined in ESG Self-Certification.

Agency/Staff Certification

I certify that, to the best of my knowledge and belief, all the information presented and attached to this form is true, accurate, and complete. I certify that, to the best of my knowledge and belief, that the individual or family above meets all eligibility requirements for Rapid Re-Housing services and that I am not related to the individual or family through family, business, or other personal ties. I certify that neither I nor anyone related to me has received or will receive any financial benefit for this eligibility determination. I understand that fraud is investigated by the Department of Housing and Urban Development, Office of Inspector General, and may be punished under Federal laws to include, but not limited to 18 U.S.C. 1001 and 18 U.S.C. 641. I also understand that if any of these certifications are found to be false, I will be subject to criminal, civil, and administrative penalties and sanctions. Staff Signature: Date:

Staff Supervisor Signature: Date: