Money Follows the Person
Qualified Residence Certification Form
Home Owned or Leased by a Family Member
Transition Coordinators will use this form to verify that the MFP Demonstration Enrollee residence in a home which is
owned or leased by a family member, 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: __________
If the home is leased, please check 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.
For all homes, whether owned or leased:
_______2. No more than 4 unrelated individuals live in this unit.
_______3. Please certify the home 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
_______4. The home and property have lockable* access and egress.
o Full control of access to and egress from the home must be present.
o Full control of access to and egress from the property must be present
*example: key pad, ID card, watchman, or key
_______5. If the home will be occupied by any children under 6, a building permit showing that the home was built
after 1978 or lead paint abatement paperwork has been provided. A copy has been retained in the enrollee’s file.
_______6. Based on answers documented above, the home meets all requirements as an MFP Qualified Residence, as
defined under the MFP Demonstration.
By signing below, I certify that all of the above requirements have been met.
Signature of Transition Coordinator _________________________________
Date __________________
