Revised 11/1/18
SPECIAL NEEDS POPULATION CERTIFICATION FORM
FOR PROJECTS FUNDED WITH LOW INCOME HOUSING TAX CREDITS
(5% SET ASIDE OR SUPPORTIVEW HOUSING CYCLE)
Name of Project: _________________________ LITC #: ______________
HMFA #: ______________
SN #: ______________
This is to certify that the following tenants meet the definition of an “Individual with Special
Needs”. * Use additional sheets as necessary.
TENANT NAME TYPE OF SPECIAL NEEDS POPULATION
1. _______________________________ _______________________________
2. _______________________________ _______________________________
3. _______________________________ _______________________________
4. _______________________________ _______________________________
5. _______________________________ _______________________________
6. _______________________________ _______________________________
7. _______________________________ _______________________________
8. _______________________________ _______________________________
9. _______________________________ _______________________________
10. _______________________________ _______________________________
Name of Social Service Provider(s): _____________________________________________
Please attach a letter on letterhead from the referring social services agency/provider for
each tenant indicating that the individual(s) is/are a client and eligible to receive services.
_____________________________________ Date: _________________________
Owner’s Signature
______________________________________________________________________________
Print Name and Title
* Definitions:
“Individuals with specials needs” means individuals with mental illness, individual with physical or
developmental disabilities and individuals in other emerging special needs groups identified by State agencies.
NJHMFA acknowledged special needs populations also include victims of domestic violence; ex-offenders
and youth offenders; youth aging out of foster care, runaway and homeless youth; individuals and families
who are homeless; disabled and homeless veterans; and individuals with AIDS/HIV.
“Individuals with mental illness” means individuals with a psychiatric disability or individuals with a mental
illness eligible for housing or services funded by the Division of Mental Health Services in the Department of
Human Services.
“Individuals with developmental disabilities” means an individual with a severe, chronic disability with a
severe chronic disability, which is attributable to a mental or physical impairment or combination of mental or
physical impairments; is manifested before the person attains age 22 and is likely to continue indefinitely. The
disability results in substantial functional limitations in three or more of the following areas of major life
activity: life-care; receptive or expressive languages; learning; mobility; self-direction; capacity for
independent living; and economic sufficiency; and reflects the person’s need for a combination and sequence
of special, interdisciplinary, or generic care, treatment or other services that are of lifelong or extended
duration and are individually planned and coordinated.
“Homeless individuals or families” mean any individual or family that does not have stable housing.
Individuals coming out of a State psychiatric hospital, transitional living program, half-way house, jail or
correctional facility, with no place to live may be considered homeless.
