Division of Mental Health Permanent Supportive Housing Bridge Subsidy Initiative Transition Funds Requisition Form (A) and Checklist (B)

Transcription

1 Division of Mental Health Permanent Supportive Housing Bridge Subsidy Initiative Transition Funds Requisition Form (A) and Checklist (B) : / / Name of Consumer: Address of Housing Unit: Move-in : / / Total Amount of Monthly Rent: $ Name of Care Manager: _ Name of Mental Health Center: Address of Care Manager: Phone # for Care Manager: Fax # for Care Manager: Address for Care Manager: Congratulations on being selected for the Division of Mental Health Permanent Supportive Housing Bridge Subsidy Initiative and locating a housing unit! You are eligible for transition funds to assist you in moving to your unit up to a maximum of $2,000. Please note that the lifetime limit for transition funds through the Permanent Supportive Housing Bridge Subsidy Initiative is $2,800 with prior approval. In order to access transition funds, you must complete parts A and B of this document and follow the steps outlined here. You cannot use transition funds as reimbursement for purchases you have already made with your personal funds. Transition funds will be paid either directly to a third party for items such as security or utility deposits or through a bank card provided to your care manager. 1. Once you have located and been accepted into a housing unit, please work with your care manager to outline the resources you need utilizing Forms A and B on the following pages of this document. 2. Complete the Transition Funds Requisition Form A (pages 1-4 of this form) and send Form A (pages 1-4) via mail or fax to your Subsidy Administrator using the contact information in Attachment A of this document. 3. Upon receipt of Form A, the Subsidy Administrator will: Write and send the requested checks to the appropriate third parties Verify the transition funds amount remaining Sign page 4 of this document and fax pages 1-4 to the Illinois Community Action Association (ICAA) at (217) You and your Care Manager will subtract any requests made in Form A from the $2,000 maximum as outlined in Form B on page 5 to estimate funds remaining. 5. You will complete Form B with your Care Manager outlining your anticipated expenses for movein needs. 6. When you have completed Form B, your Care Manager will send it to your Regional Housing Support Facilitator using the contact information in Attachment B. 7. Your Regional Housing Support Facilitator will review Form B and discuss any needed changes with your Care Manager. The RHSF will then sign Form B and fax it to your Care Manager. Page 1 of 8

2 8. Your Care Manager must then fax the signed Form B to the Illinois Community Action Association (ICAA) at (217) Upon receipt of signed Form A from the Subsidy Administrator and signed Form B from the Care Manager, ICAA will load a bank card with the remaining funds and send it with a copy of pages 1-6 to the Care Manager listed on page 1 of this document. Your Care Manager is responsible for the bank card and is the only person authorized to use it. He or she is responsible for any unauthorized purchases made with the card. 10. Once your Care Manager has received the bank card from ICAA you and your Care Manager together may proceed with making approved purchases. 11. PLEASE NOTE: Any changes to the items approved for purchase by your RHSF in Form B must be resubmitted to the RHSF for approval, re-signed by the RHSF and then resubmitted to the Illinois Community Action Association (ICAA) at (217) You may not purchase any items unless you have a signed approval to do so. 12. As purchases are made with your bank card, you must sign each receipt to indicate that you were present at the time the purchase was made. Your Care Manager will also need to fill in the actual expenses column of Form B and KEEP ALL ORIGINAL RECEIPTS. 13. You and your Care Manager must initial in the Resource Received column upon receipt of each of the listed resources. 14. Your Care Manager will make a copy of your original receipts for your own records, and submit the originals, along with the bank card, within 10 business days of completing your last purchase to the Regional Housing Support Facilitator. 15. Your RHSF will review the actual expenses and receipts and sign a second time at the bottom of page 6. The RHSF will then submit the original receipts along with signed Form B to the Illinois Community Action Association for reconciliation at 3435 Liberty Drive, Springfield, Illinois 62704, (217) (phone), (217) (fax) Page 2 of 8

3 Transition Funds Requisition Form A Consumer and Care Manager should complete this form together and submit it to the Subsidy Administrator as detailed on Pages 1-2 of this document. Requisition Form Check Request for Security Deposit Amount Requested: $ Name of Landlord: Address of Landlord: Landlord Phone Number: Landlord Fax Number: Check Request for Landlord Fees (some landlords may charge a fee in lieu of a security deposit) Amount Requested: $ Reason for Fee(s): Name of Landlord: Address of Landlord: Landlord Phone Number: Landlord Fax Number: Check Request for Utility Deposit 1 Amount Requested: $ Name of Utility Company: Address of Utility Company: Utility Phone Number: Utility Fax Number: Check Request for Utility Deposit 2 Amount Requested: $ Name of Utility Company: Address of Utility Company: Utility Phone Number: Utility Fax Number: Check Request to reimburse Mental Health Center (MHC) for costs incurred during housing search*: Amount Requested: $ Page 3 of 8

4 Transition Funds Requisition Form A Reason for Requested Amount (application fees, etc.):_ Name of Mental Health Center: MHC Phone Number: MHC Fax Number: *Eligible expenses under this item are only application fees paid on behalf of a consumer to landlords and limited transportation expenses such as bus tokens to directly assist a consumer in acquiring housing. Staff transportation cannot be reimbursed under this item. Signatures I certify that I have approved the check requests outlined on this form to facilitate the transition of the above-named consumer. Signature of Care Manager / / AREA BELOW THIS LINE ON PAGE 4 TO BE FILLED OUT BY SUBSIDY ADMINISTRATOR ONLY Subsidy Administrator will complete this section and submit pages 1-4 to the Illinois Community Action Association as detailed on pages 1-2 of this document. As the subsidy administrator for the consumer named on this form, I certify with my signature below that the following checks have been written for the identified amounts and sent to the appropriate third parties as detailed in this table: = $2000 Total Allowed Funds Security Deposit Landlord Fees Utility Deposit 1 Utility Deposit 2 Mental Health Center Reimbursement Total Remaining Funds Available for Checklist Items Signature of Subsidy Administrator Printed Name of Subsidy Administrator Page 4 of 8

5 Transition Funds Checklist Form B Consumer and Care Manager should complete this form to determine move-in item needs and submit it first to the Regional Housing Support Facilitator and then to the Illinois Community Action Association. The actual expenses column should be filled in as items are purchased and the consumer and care manager should both initial the document as each item is received. Once all purchases are completed, submit this form, along with all original receipts, to the Regional Housing Support Facilitator within 10 business days. Name of Consumer: Move-in : / / Name of Care Manager: _ Name of Mental Health Center: Address of Care Manager: Phone # for Care Manager: Fax # for Care Manager: Address for Care Manager: Complete the following table to determine total estimated remaining Transition Funds after all requisitions. Your care manager will be issued a bank card for the actual amount as outlined on Page 1. Please note that you may only use these funds to purchase eligible items that have been listed below and approved by your care manager and the Regional Housing Support Facilitator. $2000 Total Allowed Funds Security Deposit Landlord Fees Utility Deposit 1 Utility Deposit 2 Mental Health Center Reimbursement = Total Estimated Remaining Funds Available for Checklist Items Below Transition Funds Checklist Category Resource Needed Estimated Cost Bedroom Bed (mattress, box spring, frame) Bed linens (sheets, blankets, bedspread) Dresser Nightstand Alarm Clock Radio Mirror Bathroom Bath linens (towels, washcloths, bathmat) Shower curtain and rod Personal hygiene products (soap, shampoo, toothpaste, etc.) Kitchen *Food (maximum $200) Pots and Pans Page 5 of 8 Actual Cost Resource Received

6 Category Resource Needed Estimated Cost Actual Cost Resource Received Dishes (plates, cups, bowls, utensils) Coffee Pot Microwave Garbage can Living and Dining Room Couch or Futon Dining room or kitchen table and chairs Armchair Small area rugs Lamp(s) End table(s) Bookcase Curtains Miscellaneous Household Items Iron and ironing board Fan Vacuum cleaner/sweeper Cleaning supplies (mop, broom) Cleaning products (dish soap, disinfectant) Small television (maximum allowable amount for this item is $200) Other: Please list and describe any additional items needed. An example of other would be an item needed to accommodate a medical condition and supported by a physician s note. *Food is an allowable expense only if there are no other resources available. This may occur if a consumer is in the process of waiting for a LINK card or other food benefit source. Signatures I certify that I have approved the transition checklist items outlined on this form to facilitate the transition of the above-named consumer. Signature of Care Manager / / I certify that I have reviewed Form B of this document and have approved the listed estimated expenses. Signature of Regional Housing Support Facilitator / / I certify that I have reviewed and approved the actual expenses listed on Form B of this document and have received corresponding original receipts for all purchases. Signature of Regional Housing Support Facilitator / / Page 6 of 8

7 Attachment A: Subsidy Administrator Contact Information /City Covered Christian Cook City of Decatur Du Page Kendall Lake Montgomery City of Rockford Shelby Will All cities/ counties not listed above Name of Agency Contact Person Contact Phone Address Christian Integrated Community Services Catholic Charities of Chicago Decatur Housing Authority Du Page Housing Authority Du Page Housing Authority Catholic Charities of Chicago Christian Integrated Community Services Rockford Housing Authority Christian Integrated Community Services Housing Authority of Joliet Illinois Association of Community Action Agencies Elisia Evans (217) South Locust P.O. Box 80 Pana, Illinois Eileen Higgins (312) West Lake Street Chicago, Illinois Tom Smith (217) E. Locust Lorraine Hocker Lorraine Hocker (630) x. 203 (630) x. 203 Decatur, Illinois E. Roosevelt Road Wheaton, Illinois E. Roosevelt Road Wheaton, Illinois Eileen Higgins (312) West Lake Street Chicago, Illinois Elisia Evans (217) South Locust P.O. Box 80 Pana, Illinois Carol Washington or Ann Higgins (815) S. Winnebago Street Rockford, Illinois Elisia Evans (217) South Locust P.O. Box 80 Pana, Illinois Joyce Johnson or Quo V. Hightower (815) x. 133 or 159 Tami Rechner (217) x South Broadway Street Joliet, Illinois Liberty Drive Springfield, Illinois Page 7 of 8

8 Attachment B: Regional Housing Support Facilitator Contact Information DMH Region Region 1 North Region 1 Central Region 1 South Regional Housing Support Facilitator Phone Fax Address Ann Reiher (773) (773) Chicago-Read Mental Health Center 4200 N. Oak Park Avenue Chicago, Illinois Gordon Reiher (708) (708) Madden Mental Health Center 1200 S. First Avenue Hines, Illinois Anne Moore (708) (708) Tinley Park Mental Health Center 7400 W. 183 rd Street Region 2 Jaya Patel (847) ext Tinley Park, Illinois (847) Elgin Mental Health Center 750 State Street Elgin, Illinois Region 3 Joel Abramowitz (217) (217) Andrew McFarland Mental Health Center 901 Southwind Road Springfield, Illinois Region 4 Ruth Hibberd- Anderson Region 5 Tracey Boyd (618) ext (217) (217) Andrew McFarland Mental Health Center 901 Southwind Road Springfield, Illinois (618) Clyde Choate MH and DD Center 1000 North Main Street Anna, Illinois Page 8 of 8