"Homeless Voucher Nomination Form" - Salem, Oregon

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Download "Homeless Voucher Nomination Form" - Salem, Oregon

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HOUSING AUTHORITY OF THE CITY OF SALEM
HOMELESS VOUCHER NOMINATION FORM
Nomination Date:________________
To be eligible for a Homeless Voucher the family must have lived in the Salem area for the past 6-
months;
As the referring agency partner you certify that this family has lived in the Salem area for the past 6-
months?
Yes
No (If no, the family is not eligible for a Homeless Voucher Nomination)
Where has the family resided in the past 6-months?
Head of Household
Last
First
Middle
Date of Birth
Social Security #
Other Adult
Last
First
Middle
Date of Birth
Social Security #
If there is other adults age 18 or over in the household, you must provide name and Social Security # on
a separate page and attach to this form.
Other Household Members
Name
Age
Name
Age
Name
Age
Name
Age
Name
Age
Name
Age
Where is family currently residing?
Has the Family voluntarily declined or refused any other forms of housing assistance in the past 12-
months?
Yes
No
If the answer is yes, please explain
HOUSING AUTHORITY OF THE CITY OF SALEM
HOMELESS VOUCHER NOMINATION FORM
Nomination Date:________________
To be eligible for a Homeless Voucher the family must have lived in the Salem area for the past 6-
months;
As the referring agency partner you certify that this family has lived in the Salem area for the past 6-
months?
Yes
No (If no, the family is not eligible for a Homeless Voucher Nomination)
Where has the family resided in the past 6-months?
Head of Household
Last
First
Middle
Date of Birth
Social Security #
Other Adult
Last
First
Middle
Date of Birth
Social Security #
If there is other adults age 18 or over in the household, you must provide name and Social Security # on
a separate page and attach to this form.
Other Household Members
Name
Age
Name
Age
Name
Age
Name
Age
Name
Age
Name
Age
Where is family currently residing?
Has the Family voluntarily declined or refused any other forms of housing assistance in the past 12-
months?
Yes
No
If the answer is yes, please explain
Has any family member previously received housing assistance from another housing agency in the past
three years?
Yes
No
If yes, what is the name of the agency and the state in which they received assistance and what form of
assistance did they receive?
Why are you nominating this family for a Homeless Voucher?
How long has your agency been serving this family?
Year’s _______
Months _______
Gross monthly income $ __________ Source(s) of income ____________________________________
Does the family need an interpreter?
Yes
No
Language: ______________________
Is your agency represented at the monthly Emergency Housing Network Meeting?
Yes
No
Please provide the name of the individual in your agency that will assist this family in the process and
whom we may contact for further information:
Name:
Date:
Agency:
Phone #:
Address
Fax:
Email:
Mail form to Heather Jones, TBHS Dept., Housing Authority of the City of Salem, 360 Church Street SE, Salem,
Oregon 97301 or fax form to (503) 588-6465 (attention to Heather Jones) or e-mail to
hijones@cityofsalem.net
The Fair Housing Act prohibits discrimination in the sale, rental, or financing of housing on the basis of race, color, religion,
sex, handicap, familial status, or national origin. Federal law also prohibits discrimination on the basis of age. Complaints
may be forwarded to the Administrator, USDA, Washington DC 20250
The Housing Authority of the City of Salem does not discriminate against any person due to disability, race, color, religion, sex,
source of income, familial status, national origin, actual or perceived sexual orientation, gender identity, marital status,
and/or domestic partnership in accessing, applying for or receiving assistance, or in treatment or employment in any of its
programs and activities.
Complaints regarding accessibility of the Authority’s programs to individuals should be submitted to Dominique Donaho,
Salem Housing Authority, 360 Church Street SE Salem, Oregon 97301 or at
ddonaho@cityofsalem.net
Questions or comments
may also be made by phone at 503-588-6368 or 411 for hard of hearing clients; appropriate auxiliary aids (interpreters,
readers, assistance filling out forms, etc. will be provided upon request.
HOMELESS VOUCHER NOMINATION CRITERIA AND GUIDELINES
1. Eligible clients must be nominated in writing by representatives of agencies or organizations that
are participating members of the SHA-sponsored Emergency Housing Network.
2. Priority is given to families with children, disabled individuals, or to elderly families where one
family member is at least 62 years of age.
3. Nominees who are required to register as a sex offender are ineligible for the Homeless Voucher
Program.
4. Nominees must have verifiable income of less than 50 percent of median family income per
current HUD-published income limits for initial admission.
5. Nominees must meet the definition of actually without housing as defined as a family who has
maintained residency within the Salem Urban Growth Boundary, who is actually without housing
through no fault of their own.
6. Nominees’ last place of residency prior to homelessness must have been residing in the Salem
Urban Growth Boundary for the last 6-months.
7. Nominees who have declined the offer of another form of housing assistance in the past 12
months will be determined ineligible.
8. Nominees who have voluntarily given up any form of housing assistance in the past 24-months
(with the exception of those individuals who can demonstrate that they have been victims of
domestic violence, dating violence, sexual assault, or stalking) will be determined ineligible.
9. Nominees who have been evicted or terminated from any housing program as defined by the
Housing Act of 1937 will be determined ineligible.
10. Up to ten (10) Homeless Vouchers may be issued each month that Salem Housing Authority is
able to issue vouchers.
11. The Section 8 Housing Manager or his/her designee will review the nominations for program
eligibility. Nominees determined to be ineligible for the Homeless Voucher Program will be
encouraged to apply for other SHA programs, if eligible.
12. Decisions to approve or deny nominations are made solely at the discretion of Salem Housing
Authority.
13. Families who receive a Homeless Voucher must lease-up within Salem Housing Authority’s
jurisdiction (Salem Urban Growth Boundary) for 12-months prior to being allowed to transfer
their assistance (port-out) to another jurisdiction.
SHA does not automatically place nominees on the Section 8
waiting list; the nominating agency should encourage the
family to apply for housing assistance as appropriate.
KEY POINTS FOR AGENCIES ON THE NOMINATION PROCESS
 Nominations must be received by SHA by the last working day of the month preceding the
drawing. Drawings will take place during the first week of every month; notification letters
will be mailed within 5 working days of the drawing.
 One nomination per family per month will be accepted; Please ask clients if they have been
nominated by other agencies, if so please do not fill out another nomination form as it will be
thrown out.
 Nomination forms should be completed by the case manager together with the client for full,
accurate information.
 It is important that the client meets all eligibility criteria. Once a name is drawn, if the client
fails to meet the eligibility criteria SHA DOES NOT DRAW A REPLACEMENT NAME.
 By submitting a nomination, the agency agrees to provide assistance the client may require
to successfully complete the process (e.g. appointment reminders, help obtaining
verifications, etc.).
 Drawing results, eligibility packets, and appointment letters will be mailed to the nominating
case manager; once you have received correspondence from SHA, please be sure to contact
your client.
 Nominations not drawn may be resubmitted the next month, providing that
o You are still working with the nominee; and
o You write your name and date submitted on the top of the nomination form.
 Employees of Salem Housing Authority may not submit nominations as it may be considered
a conflict of interest.
 If you are not sure if a client meets the criteria as set forth, please contact Phil S Dean,
Section 8 Manager at
pdean@cityofsalem.net
I have read and agree with the nomination criteria and certify that to the best of my
knowledge the nominee meets these criteria.
Name: __________________________________________________
Signature: _______________________________________________
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