"Residential Property Approval and Authorization Form" - Delaware

This "Residential Property Approval and Authorization Form" is a document issued by the Delaware Health and Social Services specifically for Delaware residents with its latest version released on May 9, 2017.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Delaware Health and Social Services.

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Download "Residential Property Approval and Authorization Form" - Delaware

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DIVISION OF DEVELOPMENTAL DISABILITIES SERVICES
RESIDENTIAL PROPERTY APPROVAL AND AUTHORIZATION
NAME OF AGENCY:
1.
TYPE OF PROPERTY (Check One):
COMMUNITY LIVING ARRANGEMENT
2.
NEIGHBORHOOD GROUP HOME
PROPERTY ADDRESS:
3.
CITY:
STATE:
ZIP:
COUNTY:
PROPERTY DETAILS
4.
PER ADA STANDARDS, IS THE PROPERTY ACCESSIBLE?: (Check One)
YES
NO
A.
IF YES, COMPLETED UNIVERSAL DESIGN SCORESHEET MUST ACCOMPANY THIS FORM
B. NUMBER OF LICENSED/CERTIFIED BEDS:
(Check One):
1
2
3
4
5
HOW MANY BEDROOMS ARE INTENDED TO BE USED FOR SLEEPING QUARTERS?
C.
(Check One):
1
2
3
4
5
OCCUPANTS – ENTER ONLY DDDS CONSUMERS BELOW:
5.
ENTER DDDS CONSUMER FIRST NAME AND LAST NAME AS WELL AS DATE OF BIRTH (DOB).
A.
IF ALL CONSUMERS RESIDING AT SITE HAVE NOT BEEN IDENTIFIED FOR PLACEMENT LIST
AS “VACANT” AND INDICATE ANTICIPATED DATE VACANCY WILL BE FILLED.
FIRST NAME
LAST NAME
DOB:
1.
DOB:
2.
DOB:
3.
DOB:
4.
5.
DOB:
YES
NO
B. DO CONSUMERS HAVE SPECIAL PROGRAMMATIC NEEDS? (Check One)
IF YES, COMPLETED PROGRAMMATIC ASSESSMENT FORM MUST ACCOMPANY THIS FORM
PAGE 1 (OF FOUR)
DIVISION OF DEVELOPMENTAL DISABILITIES SERVICES
RESIDENTIAL PROPERTY APPROVAL AND AUTHORIZATION
NAME OF AGENCY:
1.
TYPE OF PROPERTY (Check One):
COMMUNITY LIVING ARRANGEMENT
2.
NEIGHBORHOOD GROUP HOME
PROPERTY ADDRESS:
3.
CITY:
STATE:
ZIP:
COUNTY:
PROPERTY DETAILS
4.
PER ADA STANDARDS, IS THE PROPERTY ACCESSIBLE?: (Check One)
YES
NO
A.
IF YES, COMPLETED UNIVERSAL DESIGN SCORESHEET MUST ACCOMPANY THIS FORM
B. NUMBER OF LICENSED/CERTIFIED BEDS:
(Check One):
1
2
3
4
5
HOW MANY BEDROOMS ARE INTENDED TO BE USED FOR SLEEPING QUARTERS?
C.
(Check One):
1
2
3
4
5
OCCUPANTS – ENTER ONLY DDDS CONSUMERS BELOW:
5.
ENTER DDDS CONSUMER FIRST NAME AND LAST NAME AS WELL AS DATE OF BIRTH (DOB).
A.
IF ALL CONSUMERS RESIDING AT SITE HAVE NOT BEEN IDENTIFIED FOR PLACEMENT LIST
AS “VACANT” AND INDICATE ANTICIPATED DATE VACANCY WILL BE FILLED.
FIRST NAME
LAST NAME
DOB:
1.
DOB:
2.
DOB:
3.
DOB:
4.
5.
DOB:
YES
NO
B. DO CONSUMERS HAVE SPECIAL PROGRAMMATIC NEEDS? (Check One)
IF YES, COMPLETED PROGRAMMATIC ASSESSMENT FORM MUST ACCOMPANY THIS FORM
PAGE 1 (OF FOUR)
6. REASON WHY FORM IS BEING SUBMITTED (Check One):
OPENING NEW RESIDENTIAL SITE (IF NEW SITE REPLACES EXISTING
SITE, LIST ADDRESS CLOSING):
RENEWING A PROPERTY ALREADY IN OPERATION
A.
LIST UTILITIES & SERVICES INCLUDED WITHIN THE LEASE/FINANCE AMOUNT.
GAS
WATER
ELECTRIC
OIL
SEWER
TRASH
SNOW RMVL
CABLE
PHONE
LIST UTILITIES & SERVICES NOT INCLUDED WITHIN THE LEASE AMOUNT.
B.
GAS
WATER
ELECTRIC
OIL
SEWER
TRASH
SNOW RMVL
CABLE
PHONE
C.
ESTIMATED MONTHLY PAYMENT FOR UTILITIES/SERVICES CHECKED IN # 6 B:
$
(If leased proceed to Section #7A;
IS PROPERTY (Check One)
OWNED
LEASED
7.
If owned proceed to Section #7B)
IF LEASED, ATTACH LEASE COPY GOING INTO EFFECT
PROPERTY LEASE DETAILS
A.
LESSOR NAME:
i.
ii.
LESSOR ADDRESS:
REPRESENTATIVE:
iii. LESSOR PHONE:
iv. LEASE TERM:
EFFECTIVE DATE:
ENDING DATE:
$
v. MONTHLY LEASE AMOUNT:
$
IF RENEWING, PREVIOUS MONTHLY LEASE AMOUNT WAS:
$
vi. MONTHLY AMOUNT OF RENTER'S INSURANCE:
PAGE 2 (OF FOUR)
IF OWNED, ATTACH COPIES OF:
B.
IF OWNED, ATTACH COPY OF MORTGAGE/FINANCE DOCUMENTS IF PROPERTY NOT PAID IN FULL,
PROPERTY INSURANCE CERTIFICATE AND PROPERTY & SCHOOL TAX STATEMENT
$
i.
MONTHLY MORTGAGE/FINANCE AMOUNT:
(CAN INCLUDE PRINCIPAL& INTEREST)
ii.
FINANCE PERIOD:
EFFECTIVE DATE:
ENDING DATE:
iii. NAME OF LENDER:
iv. INTEREST RATE:
$
v.
MONTHLY PROPERTY TAXES:
$
vi.
MONTHLY SCHOOL TAXES:
$
vii. MONTHLY HOME OWNER'S INSURANCE:
viii.
DOES LENDER REQUIRE RESERVES FOR REPAIRS/MAINTENANCE?
(Check One)
YES
NO
IF YES, ENTER MONTHLY RESERVE AMOUNT:
$
IS PROPERTY FINANCED BY DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT (HUD)?
8.
(Check One)
YES
NO
WHAT IS FAIR MARKET RENTAL (FMR) PER HOUSING & URBAN DEVELOPMENT?
9.
$
PROVIDER ATTESTATION STATEMENT
I ATTEST THAT THE INFORMATION REPORTED ON THIS FORM IS TRUE TO THE BEST OF MY
KNOWLEDGE AND ALL QUESTIONS ARE ANSWERED HONESTLY. I ALSO ATTEST NO INFORMATION
WAS WITHHELD, EITHER INTENTIONALLY OR UNINENTIONALLY, WHEN COMPLETING THIS FORM.
SUBMITTED BY:
Signature of Authorized Agency Representative
Date
Title
PAGE 3 (OF FOUR)
FOR OBCBS USE ONLY -FUNDING APPROVAL/DENIAL
RESIDENTIAL PROPERTY LISTED ABOVE IS:
APPROVED - LEASE VALUE IS EQUAL TO OR LESS THAN HUD FMR
APPROVED - LEASE VALUE EXCEEDS HUD FMR BUT DDDS APPROVES FOR
PROGRAMMATIC, ACCESSIBILITY AND/OR GEOGRAPHIC REASONS.
(See Attached Residential Property Review & Decision)
DENIED. REASON LISTED BELOW.
THE AUTHORIZED REPRESENTATIVE OF DHSS, DIVISION OF DEVELOPMENTAL DISABILITIES
SERVICES, HEREBY AUTHORIZES THE PROVIDER TO EXECUTE THE ABOVE REQUESTED LEASE OR
LEASE RENEWAL.
EVALUATED BY:
Signature of DDDS OBCBS Management Analyst
Date
AUTHORIZED BY:
Signature of DDDS OBCBS S.S.Chief Administrator
Date
PAGE 4 (OF FOUR)
Last Updated: 5/9/17
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