Charleston – Kanawha Housing Authority
Shelter Plus Care Program
Eligibility Packet
GENERAL INFORMATION
• For help with this form, contact CKHA at (304) 348-6451 or www.ckha.com.
• FAX completed eligibility packet to CKHA at (304) 348–8155 or drop off to administrative office
located at 1525 Washington Street West, Charleston, WV 25387.
• Download this form as a PDF file at www.ckha.com/forms.htm.
DETAILED PROGRAM INFORMATION
• For an overview of CKHA’s Shelter Plus Care program, visit www.ckha.com/adminplan.htm.
REQUIRED DOCUMENTS
All adults in households seeking assistance must have the following in order to receive assistance: a
state-issued picture ID, Birth Certificate, Social Security Card, and proof of income, if any, for all
household members. If any of these items are missing, you should begin to work on obtaining them
immediately. All documents must be turned in before your initial briefing at CKHA administrative office.
The briefing is your required first step in Shelter Plus Care before looking for a rental until.
An incomplete eligibility packet slows review time and delays housing assistance.
For the fastest possible determination of eligibility:
• Be sure you have the most current version of the Eligibility Packet before you begin. You
can check for the latest version by visiting www.ckha.com/forms/htm.
• Read the instructions found throughout the packet to be sure you are filling it out correctly. If
you have a question or need help, it’s better to contact CKHA first than to submit a packet you’re
not sure is complete and correct.
• Know what the head of household’s housing status is. Only persons who are chronically
homeless per HUD’s definition are eligible for Shelter Plus Care assistance. Per HUD, chronically
homeless is defined as “either (1) an unaccompanied homeless individual with a disabling
condition who has been continuously homeless for one year or more, OR (2) an unaccompanied
individual with a disabling condition who has had at least four episodes of homelessness in the
past three years.” “Homeless” is defined as “a person sleeping in a place not meant for human
habitation (e.g. living on the streets, for example) OR living in emergency shelters, or who are
currently living in institutions, or transitional housing programs. If your client does not meet the
definition of ‘chronic homeless,’ he or she is not eligible for Shelter Plus Care assistance.
• Include documentation of the household’s homelessness. This is required. No household can
be found eligible for assistance without documentation of homelessness. See the Instructions on
the next page for more information on what constitutes eligible homelessness and how to
document it.
• Make sure this form is legible and will remain so after you fax it to us. Use only dark-colored
ink.
• Save time and paper – don’t fill out and fax us pages we don’t need. Don’t fax us these
instructions or the Eligibility Packet Checklist.
Revised 01/2020
Charleston – Kanawha Housing Authority
Shelter Plus Care Program
Eligibility Packet Instructions
HOW TO DOCUMENT EPISODES OF HOMELESSNESS
In Attachment B, “Verification of Homelessness,” choose one of three situations that describe the Head of Household’s
current homelessness situation, and then describe in detail any prior episodes of homelessness for the past three years.
Include documentation of each episode of homelessness described on Attachment B. Listed below are the situations that
qualify a head of Household as homeless, and how to document them.
1. ‘Street’ homelessness: a primary nighttime residence that is a public or private place not designated for or ordinarily
used as a regular sleeping accommodation for human beings; includes places like a car, a park, an abandoned
building, a camping ground, sleeping in a tent in the woods, etc.
How to document it: The above situation should be personally observed and verified, and described in a letter.
Normally this is written by the Head of Household’s referring agency contact person, but a third party may also be
able to verify homelessness, such as an outreach worker, law enforcement, or other person who has witnessed the
situation. In the letter, include specific locations, dates, and describe in what way the situation constitutes a place not
meant for human habitation. The letter must be on agency letterhead, and must be signed and dated by the author. In
cases where the street homelessness occurred in the past, it can be self-reported by the household, and then detailed
in the letter.
2. Emergency shelter: a supervised publicly or privately operated shelter designated to provide temporary living
arrangements. This includes emergency shelters, domestic violence shelter, transitional housing, and hotels and
motels paid for by charitable organizations or by federal, state, or local government programs for low-oncome
individuals.
How to document it: For shelters, obtain a letter from the facility verifying the date(s) of entry and exit and that the
Head of Household currently resides there, if applicable; or a printout from ServicePoint HMIS systems showing
recorded shelter stays.
For transitional housing programs, obtain a letter from the transitional housing program verifying the dates of
residence by the Head of Household; and documentation that the Head of Household’s housing immediately prior to
the transitional program was an emergency shelter, or a place not meant for human habitation (same documentation
as detailed above).
For an emergency stay in a hotel or motel, obtain a letter from the agency that paid for the stay, stating the dates
paid for and the reason, and a copy of the hotel/motel receipt.
3. Institutional stays: a person is considered homeless if he or she is exiting an institution where he or she stayed for
90 days or less and lived in an emergency shelter, or a place not meant for human habitation immediately before
entering the institution. An institution includes a medical or psychiatric hospital; an in-patient treatment program; a
nursing home, respite bed situation, or other typically congregate setting; and jail or other correctional facilities.
How to document it: Obtain a signed and dated letter from the institution verifying that the Head of Household has
lived there for ninety days or less and is about to exit the institution; and documentation that the Head of Household’s
housing immediately prior to the institution was either an emergency shelter, or a place not meant for human
habitation (same documentation as described in 1 and 2, above).
Homelessness should be documented in the following order: 1) Third party, 2) Intake Worker, then 3) Self-Certification.
Charleston – Kanawha Housing Authority
Shelter Plus Care Program
Eligibility Packet Checklist
The purpose of this checklist is to help you complete a Shelter Plus Care Eligibility Packet. Please do not send
this page with the Eligibility Packet.
Sections 1-7 of the form are filled out completely. Skip Section 3 if there are no other adults in the
household; skip Section 4 if there are no minors in the household.
The Head of Household has signed the Head of Household Certifications (Section 6).
The referring agency contact person has signed the Referring Agency Certifications (Section 7).
Attachment A (Disability Verification) is completely filled out with one option checked; is signed by a
person with the proper credentials; and the signer has listed his or her license number.
Attachment B (Homelessness Verification) is completely filled out with ONE option checked and all
episodes of homelessness for the past three years have been described in detail.
All episodes of homelessness for the past three years have been documented (see Instructions for
required documentation).
Attachment C—Consent for Disclosure of Head of Household’s Protected Health Information is
completely filled out and signed by the Head of Household and a witness.
The Head of Household has, or is working on obtaining, all required forms of identification and proof of
income, if any, for all members of the proposed household.
The HMIS Data Form is:
Ready to be completed and taken to the Household’s briefing meeting after Prestera refers the
Household to CKHA.
OR
Completed and will be submitted to CKHA with this Eligibility Packet.
Shelter Plus Care Eligibility Packet
Charleston-Kanawha Housing Authority | 1525 Washington Street West | Charleston, WV 25387
304.348.6451 | FAX 304.348.8155 | www.ckha.com
➢ SECTION 1. HEAD OF HOUSEHOLD INFORMATION
First Name: ___________________________ Middle: ________________ Last Name: ___________________________
Complete Address: _________________________________________________________________________________
Social Security Number: ____________-___________-_____________ Date of Birth _________/________/________
➢ SECTION 2. REFERRING AGENCY CONTACT INFORMATION
Name: ___________________________________________________________________________________________
Agency: ____________________________________________ Office Phone: (_______) _________________________
Fax: (________) ______________________ Cell Phone: (________) _________________________
Email Adress: ____________________________________________@________________________
➢ SECTION 3. OTHER ADULTS IN THE HOUSEHOLD (Age 18+) Use an additional copy of this page if the household
has more than one other adult aside from the Head of Household
First Name: ___________________________ Middle: ________________ Last Name: ___________________________
Social Security Number: ____________-___________-_____________ Date of Birth _________/________/________
➢ SECTION 4. MINORS IN THE HOUSEHOLD (Age 17 and <)
First Name: ___________________________ Middle: ________________ Last Name: ___________________________
Does the Head of Household have legal custody of this minor? Yes No
If “yes,” please specify: full custody joint custody (minor lives with or will live with the HOH as least 50% of the time)
Social Security Number: ____________-___________-_____________ Date of Birth _________/________/________
First Name: ___________________________ Middle: ________________ Last Name: ___________________________
Does the Head of Household have legal custody of this minor? Yes No
If “yes,” please specify: full custody joint custody (minor lives with or will live with the HOH as least 50% of the time)
Social Security Number: ____________-___________-_____________ Date of Birth _________/________/________
First Name: ___________________________ Middle: ________________ Last Name: ___________________________
Does the Head of Household have legal custody of this minor? Yes No
If “yes,” please specify: full custody joint custody (minor lives with or will live with the HOH as least 50% of the time)
Social Security Number: ____________-___________-_____________ Date of Birth _________/________/________
CKHA Use Only
Forms:
Applicant
Other Adults
Disability
Homeless
Consent
Eligibilty:
Disabled
Homeless
Disability:
SMI
CSA
PWA
PWOD
Chronic:
Yes
No
➢ SECTION 5. INCOME
Head of Household: have you, or anyone who will live with you, received income from any source in the last 30 days?
Yes No If “yes,” please specify below:
Source of income (do not include non-cash sources such as food stamps and WIC): _______________________
__________________________________________________________________________________________
Total amount received per month $____________________
➢ SECTION 6. HEAD OF HOUSEHOLD CERTIFICATIONS
Head of Household: please read the statements below and sign to show that you have read the information,
understand it, and agree to it.
✓ I understand that if I am approved to receive assistance from Charleston-Kanawha Housing Authority (CKHA)’s
Shelter Plus Care program, I agree to comply with all of the rules of the Shelter Plus Care Program.
✓ I understand that I must report all increases and decreases in my income to CKHA within 10 business days of the
change of income.
✓ I understand that as a Shelter Plus Care participant I am required to comply with the terms of the lease.
✓ I certify that all information provided to me is accurate and complete to the best of my knowledge. I also
understand that making false statements or providing false information is grounds for denial or termination of
rental assistance.
_____________________________________________________________________________________
(Print Name of Head of Household, or of Parent, Guardian, or Legal Representative of Head of Household)
_____________________________________________________________________________________
(Signature of Head of Household, or of Parent, Guardian, or Legal Representative of Head of Household)
_________________________________
(Date)
➢ SECTION 7. REFERRING AGENCY CERTIFICATION
Referring Agency Contact person: please read the statements below and sign to show that you have read the information,
understand it, and agree to it.
✓ I understand that by referring this Head of Household to the Shelter Plus Care program, my agency is committing
to providing support for the Head of Household necessary for the securing of a rental unit.
✓ I will ensure that all school-age children in the household are properly enrolled in school and are connected to the
appropriate services within the community, including early childhood education programs.
✓ I will attend the initial Shelter Plus Care orientation meeting with the Head of Household at CKHA, once the Head
of Household has been approved to receive Shelter Plus Care assistance.
✓ I will assist the Head of Household in his or her housing search once the Head of Household is approved for
Shelter Plus Care assistance.
✓ I certify that all information provided by me is accurate and complete to the best of my knowledge. I also
understand that making false statements or providing false information is grounds for denial or termination of
rental assistance.
_____________________________________________________________________________________
(Print Name of Referring Agency Contact Person)
_____________________________________________________________________________________
(Signature of Referring Agency Contact Person)
_________________________________
(Date)
ATTACHMENT A. VERIFICATION OF DISABILITY
The assessed individual, ____________________________________________ (name), has been diagnosed as follows:
Serious mental illness
Chronic alcohol use disorder and/or a chronic drug use disorder
Both a serious mental illness and a chronic alcohol or drug use disorder
Severe and chronic developmental disability that:
1. Is attributable to a mental or physical impairment or combination of mental and physical impairments;
2. Manifested before the individual attained the age of 22;
3. Is likely to continue indefinitely;
4. Results in substantial functional limitations in three or more of the following areas of major life activity (please
check a minimum of three of the following):
Self-care
Receptive and expressive language
Learning
Mobility
Self-direction
Capacity for independent living
Economic self-sufficiency; and
5. Reflects the individual’s need for a combination and sequence of special, interdisciplinary, or generic services,
individualized supports, or other forms of assistance that are of lifelong or extended duration and are individually
planned and coordinated.
Diagnosis of HIV and/or AIDS
I have personally made the diagnosis specified above. The above individual has a disability that is expected to be
of long-continued and indefinite duration; is expected to substantially impede this person’s ability to live
independently; and is of such a nature that it could be improved by more suitable housing conditions.
__________________________________________ ________________________________________________
(Print Name of Person Verifying Disability) (Signature of Person Verifying Disability)
______________________________ License Number (if applicable): ____________________________________
(Date)
Please read: This form may be completed only by a person who can make one of the diagnoses listed on the form below within
their scope of professional practice, as defined by the Revised Statutes of West Virginia or by a credentialing agency
recognized by the State of West Virginia. Please indicate your professional licensure by checking a box below:
Advanced Practice Registered Nurse Licensed Clinical Social Worker
Licensed Professional Counselor Physician
Psychiatrist Psychologist
Charleston-Kanawha Housing Authority (CKHA)’s Shelter Plus Care program is a permanent supportive housing program
funded by the Department of Housing and Urban Development (HUD). HUD’s eligibility requirements for Shelter Plus Care
specify that the person receiving assistance must be considered disabled. HUD defines a disability as a condition that:
1) Is expected to be long-continuing or of indefinite duration;
2) Substantially impedes the individual’s ability to live independently; and
3) Could be improved by the provision of more suitable housing conditions.
To be considered disabled for purposes of establishing Shelter Plus Care eligibility, the diagnosis must have these
characteristics. If you agree that it does, please specify below which diagnosis the individual has, and indicate your assessment
of disability status by completing the bottom of the form. Please choose only one diagnosis. If more than one applies to this
person, choose the one that most closely fits the characteristics stated above.
ATTACHMENT B. VERIFICATION OF HOMELESSNESS
Head of Household Name: ______________________________________________________________________
The Head of Household is homeless as defined by HUD because he or she is currently:
An individual or family with a primary nighttime residence that is 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 or train station, airport, or camping ground
An individual or family living in a supervised publicly or privately operated shelter designated to provide temporary
living arrangements (including shelters, transitional housing, and hotels and motels paid for by charitable
organizations or by federal, state, or local government programs for low-income individuals).
An individual who is exiting an institution where he or she resided for 90 days or less and who resided in an
emergency shelter or place not meant for human habitation immediately before entering that institution.
Time Period Location (e.g., name of shelter or institution, physical location if ‘street’ homeless, etc.)
Examples:
Oct. 1, 2015 – Nov. 30, 2015 Client slept in her car, which was usually parked on Big Lots parking lot near Patrick
Street in Charleston, WV
July 1, 2015 – July 31, 2015 Client resided at Sojourner Shelter in Charleston, WV
______________________ ___________________________________________________________________
___________________________________________________________________
______________________ ____________________________________________________________________
____________________________________________________________________
______________________ ____________________________________________________________________
____________________________________________________________________
_______________________ ____________________________________________________________________
____________________________________________________________________
(Print Name of Person Verifying Homelessness) (Signature of Person Verifying Homelessness)
______________________________
(Date) (Name of Agency or Self Certification)
• FIRST: Check one item from the list below that describes the Head of Household’s current homelessness situation.
You must include documentation of the Head of Household’s homelessness (refer to the Instructions at the
beginning of the Eligibility Packet for how to document homelessness). No Head of Household can be found
eligible for assistance without required documentation of homelessness.
• SECOND: Use the space below to detail the Head of Household’s housing and homelessness history for the past
three (3) years. Please be as detailed as possible as to dates and locations. Describe all episodes of
homelessness that fit any of the three categories listed above. Alternatively, you may also provide this information
in a signed and dated letter (must be on your agency letterhead) and include it in the Eligibility Packet following this
form. You must also include documentation of the Head of Household’s homelessness history (refer to the
Instructions at the beginning of the Eligibility Packet for how to document homelessness).
ATTACHMENT C. CONSENT FOR DISCLOSURE OF HEAD OF HOUSEHOLD’S PROTECTED HEALTH
INFORMATION
I, (full name): _____________________________________________________________________________________,
Social Security Number: _______ - _______ - _______ Date of Birth: _______ / _______ / _______
hereby authorize CHARLESTON-KANAWHA HOUSING AUTHORITY (CKHA) and the programs, agencies and persons
listed below to communicate and disclose to one another written and verbal information regarding my protected health
information:
Current Case Manager
Homeless management information data system (HMIS)
U.S. Department of Housing and Urban Development (HUD)
local housing authority rental property owner or manager
The purpose of the disclosure is to obtain information used to secure and/or maintain rental assistance and housing
through CKHA’s rent subsidy programs Shelter Plus Care and/or Rental Assistance Program.
CKHA does not have my permission to disclose the following items: __________________________________________
_________________________________________________________________________________________________
I understand that my medical/health information records are protected under federal regulations governing Confidentiality
of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and the Health Insurance Portability and Accountability Act of
1996 (HIPAA), and cannot be disclosed without written consent unless otherwise provided for in the regulations. I
understand that by signing this authorization, I am allowing the release of my protected health information. The protected
health information in my record may include mental/behavioral health information, information relating to acquired
immunodeficiency syndrome (AIDS), human immunodeficiency virus (HIV), alcohol/drug use, and/or a developmental
disability.
I understand that I may revoke this consent at any time, except to the extent those disclosures have already been made in
reliance on this or any other consent. Revocation may be accomplished by written request and may be for specific items
or the entire release. To revoke this consent, mail a signed written request to revoke consent to: Charleston-Kanawha
Housing Authority, Director of Leased Housing, 1525 Washington Street West, Charleston, WV 25387.
I understand that this consent remains effective until I am no longer a participant in the CKHA rent subsidy program,
unless I specify expiration on the following date, or based on the following event or special condition: ________________
_________________________________________________________________________________________________
I understand that while signing this consent form is not a precondition to being declared eligible for housing assistance,
CKHA cannot complete the process of delivering such assistance to me unless I sign this consent form. I understand that
I may request to inspect or request a copy of information to be used or disclosed, as provided in 45 CFR Section 164.524.
I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the
information may not be protected by federal confidentiality rules.
Would you like a copy of this consent form? Please initial: ( ) YES ( ) NO
Signature of Consumer: __________________________________________ Date: _______ / _______ / ________
Signature of Witness: ____________________________________________ Date: _______/ _______ / ________
Signature of Parent/Guardian/Representative:
_____________________________________________________________ Date: ______ / _______ / _________
Guardian/Representative: please include a description of authority to act on Consumer’s behalf: ____________________
________________________________________________________________________________________________