Money Follows the Person
Qualified Residence Certification Form
Leased Apartment
Transition Coordinators will use this form to verify that the MFP Demonstration Enrollee residence in a leased
apartment meets the definition of an MFP Qualified Residence as defined under the MFP Demonstration. Transition
Coordinators will initial next to each item and sign at the bottom confirming that the residence meets all the items on
the list. This form will then be maintained in the Enrollee file.
Enrollee Name:
Full Address of Qualified Residence:
Transition Coordinator Please initial next to each item:
Transition Coordinator please initial the following:
________1. A Walk Through Checklist has been completed and signed by the enrollee and the landlord which indicates
any existing damage to the unit. If there appear to be any health or safety issues with the unit, please contact the local
Board of Health.
________2. No more than 4 unrelated individuals live in this unit.
________3.Enrollee has a lease for the apartment outlining the:
• amount of rent
• term of lease
• amount of security deposit, if applicable
• rights regarding security deposit, if applicable
• all the contact information including name, address, and phone number of the landlord or any person
responsible for maintaining the property
• rights regarding termination
The following clauses are NOT in the lease:
• A clause that states that a tenant is responsible for all repairs
• A clause that states the security deposit can be used to pay for utilities if the tenant doesn’t pay for them
• A clause which states that the tenant must pay for electricity or gas where the bill is in the landlord’s name
• A clause that states that upon termination of your lease the tenant must pay remaining rent due
• A clause that states that receipt of services is a condition of occupancy or that the tenant is required to
receive services from a specific company
• A clause that states that the tenant must provide notification for any periods of absence from the apartment
_______4. Please certify the apartment has the following which the participant or their family has full control over:
o Living area
o Sleeping Area
o Bathing area
o Cooking area
____
__5. The apartment has lockable* access and egress.
o Full control of apartment access and egress must be present.
*example: key pad, ID card, watchman, or key
