Fillable New York State Department of Health TBI/NHTD Housing (New York State)

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New York State Department of Health TBI/NHTD Housing (New York State)

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Attachment #3
1
New York State Department of Health TBI/NHTD Housing Program
Payment Request
Action Requested: ☐ New Application ☐ Change ☐ One Time Payment
Participant Name___________________________________________________________________________________________________________
Property Address___________________________________________________________________________________________________________
Service Coordinator Name____________________________________________________________________________________________________
Service Coordination Agency____________________________________________ Service Coordinator Phone________________________________
Type of Housing______________________________________________________ Number of Bedrooms ____________________________________
Number of Adults in Household _____________________________________ N
umber of Children in Household_______________________________
Full
Actual
Rental Cost $__________________________ Includes Utilities? ☐ Yes ☐ No Fair Market Rent for Unit $_____________________
Monthly Rental Subsidy Amount $ ________________________________________ Utility Subsidy Start Date ________________________________
Lease Start Date_____________________________________________ Lease End Date_________________________________________________
Landlord/Management Company Name_________________________________________________________________________________________
Landlord/Management Company Address________________________________________________________________________________________
Landlord/Management Company Phone_________________________________________________________________________________________
Utility Company Name (1) ________________________________________________________ Phone (1) ______________________________
(2) _________________________________________________
_______ (2) _____________________________
(3) ________________________________________________________ (3) _____________________________
Utility Company Address (1) ________________________________________________________ Account # (1) _____________________________
(2)
________________________________________________________ (2) _____________________________
(3)
________________________________________________________ (3) ____________________________
Housi
ng Choice (Section 8) Application Date _____________________________________________________________
Total Individual Monthly Income after Spend Down $______________________
Special Needs Trust? ☐ Yes ☐ No
Requested Actual Rental Subsidy $____________________ (a)
Request
ed Utility Subsidy $____________________ (b1)
$____________________ (b2)
$____________________ (b3)
One Time Payment Amount $____________________ (c)
☐ Security
☐ Household Goods
☐ Broker’s Fees
☐ Late Fees/Arrears
Total Requested Housing Subsidy $____________________ (a+b1+b2+b3+c)
Attachment #3
2
Narrative (Please include all resources attempted, special needs, reason for request, and information regarding
financial need):
Formulas for Calculating Housing and Utility Subsidy
Housing Subsidy- Participant Only
(Total Rental Amount minus Participant Share (1/3 Income after Spend Down) = Rental Subsidy Amount)
Total
Rental Amount $_________________
--
Participant Share (1/3 of Total Income) $_________________
Housing Subsidy Amount $_________________
Utilit
y Subsidy- Participant Only
(Budget Plan Monthly Payment minus Participant Share (1/3 Budget Plan Monthly Payment) = Utility Subsidy
Amount)
Budget Plan Monthly Payment (attach copy of bill) $_________________
--
Participant Share (1/3 Budget Plan Monthly Payment) $_________________
Utility Subsidy Amount $_________________
*Addi
tional pages may be used for multiple utility subsidy requests.
3
Attachment #3
Housing Subsidy- Participant with roommate or family
(Total Rental Amount minus Any Roommate Share (e.g. 1/2 or 1/3 of Total Rental Amount) = Adjusted Rent.
Adjusted Rent minus Participant Share (1/3 Total Monthly Income after Spend Down) = Housing Subsidy Amount)
Total Rental Amount $__________________
--
Any Roommate Share (e.g. 1/2 or 1/3 of Total Rental Amount) $__________________
Adjusted Rent $__________________
Adj
usted Rent $__________________
--
Participant Share (1/3 of Total Income) $__________________
Housing Subsidy Amount $__________________
Housing Subsidy- Participant Renting Room in Family Home
(½ Fair Market Rent for a One Bedroom Apartment minus Participant Share (1/3 Monthly Income after Spend
Down = Housing Subsidy Amount)
½ F
air Market Rent (One Bedroom Apartment) $__________________
--
Participant Share (1/3 of Total Income after Spend Down) $__________________
Housing Subsidy Amount $__________________
Utility Subsidy- Participant with roommate or family
(Budget Plan Monthly Payment minus ½ Budget Plan Monthly Payment = Adjusted Utilities. Adjusted Utilities
minus Participant Share (1/3 Adjusted Utilities) = Utility Subsidy)
Bud
get Plan Monthly Payment (attach copy of bill) $__________________
--
½ Budget Plan Monthly Payment $__________________
Adj
usted Utilities $__________________
Adj
usted Utilities $__________________
--
Participant Share (1/3 of Adjusted Utilities) $__________________
Utility Subsidy Amount $__________________
*Ad
ditional pages may be used for multiple utility subsidy requests
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New York State Department of Health TBINHTD Housing (New York State)

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Completed 14 August 2020

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