Form Pas 106H PDF Details

The Continuum of Care Program's Rental Assistance Intake Form, known as PAS 106H, plays a crucial role for individuals and families navigating the challenges of homelessness and seeking support. Through its comprehensive approach, the form collects essential information on the applicant's name, date of birth, social security number, current residence or contact details, alongside alternative contact means, underscoring a meticulous effort to maintain connectivity with applicants. It probes into the current living situation with an emphasis on meeting the Housing and Urban Development (HUD) definition of homelessness, including non-housing situations, utilization of emergency shelters, transitional housing, or fleeing domestic violence, thereby covering a broad spectrum of scenarios faced by those in need. Moreover, it delves into the duration and frequency of homelessness to determine chronic homelessness, which is pivotal for accessing certain services. The inclusion of disability status, with necessary documentation, and the listing of other household members establishes a detailed profile of the applicant's household, emphasizing the intertwined nature of homelessness with various social and health-related issues. Additionally, the form captures demographics, emphasizing ethnicity and race, thereby acknowledging the diverse backgrounds of applicants. The PAS 106H form also identifies special needs and qualifications for program eligibility, ranging from mental health issues to substance use disorders and physical disabilities, reflecting the program's multifaceted approach to support. Detailed financial information, including income sources and assets, is required, ensuring a thorough assessment of the applicant's economic situation. With a clear declaration and certification process, the form underscores the importance of accuracy and honesty in the application process, further complemented by a list of necessary documentation to support the application. Overall, the PAS 106H form embodies a comprehensive tool for assessment and assistance within the Continuum of Care Program, aiming to address the multifaceted challenges faced by individuals and families experiencing homelessness.

QuestionAnswer
Form NameForm Pas 106H
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other nameshomeless shelter intake forms, emergency shelter intake form, homeless shelter intake process, shelter intake form

Form Preview Example

Continuum of Care Program

Rental Assistance Intake Form

Name:

 

Date:

 

Date of Birth:

 

SS #:

 

Referring Agency:

 

Referral Person:

 

Case Manager:

 

Telephone Number:

 

Current Residence if Any:

 

 

 

 

 

Telephone Number or Other Means of Contact:

 

 

 

 

 

Alternate Means of Contact:

 

 

 

 

 

Current Living Situation (Note: Must Meet HUD Definition of Homelessness)

Please check one:

Non-housing (street, car, park, etc.)

Emergency shelter

Transitional housing after having been homeless

Fleeing/attempting to flee domestic violence

Note: If the participant came from an institution (such as a mental health/substance abuse treatment facility) but was there less than 90 days and was living on the street or in emergency shelter before entering the treatment facility, he/ she should be counted in either the street or shelter category, as appropriate.

Certificate of Homelessness is completed and attached

Can the person be considered chronically homeless (homeless continuously for one year or more or have experienced four episodes of homelessness in the past three years)?

Yes (documentation is attached) No

What is the qualifying disability?

Is documentation from a professional qualified to make a disability determination attached?

Yes

No

Other Household Members: Please list all family members who will be living in the household

Relationship

Name

Date of Birth

Age

Social Security Number

PAS-106H (Revised 10/14)

Demographics:

Please place the total number of household members in each box.

Ethnicity:

Hispanic or Latino

Non-Hispanic or Latino

Race:

American Indian

Asian

Black/African American

Native Hawaiian/ Other Pacific Islander

White

American Indian/Alaskan Native & White

Asian & White

Black/African American & White

American Indian/ Alaskan Native & Black/African American

Other Multi-Racial

Special Needs Program Qualifications: (For primary program participant only, please check all that apply): Must have a diagnosed Axis I substance use disorder to be eligible for the program)

Mental Illness

Alcohol Abuse

Drug Abuse

HIV/AIDS and related diseases

Other: (please check all that apply)

Developmental Disability

Physical Disability

Domestic Violence

Other (please specify)

Total Household Monthly Income from EACH of the following sources:

Supplemental Security Income (SSI)

Social Security Disability Income (SSDI)

Social Security

General Public Assistance

Temporary Aid to Needy Families (TANF)

Child Support

Veteran’s Benefits

Employment Income

Unemployment Income

Medicare

Medicaid

Food Stamps

Other (please specify)

No Financial Resources

Bank Accounts

Type of Account

Bank Name and Address

Amount

Checking

Savings

Other Assets:

Asset Declaration: I certify that the above listed assets are the only assets of which I am either full or partial owner, that my name does not appear on any other bank accounts, checking accounts, saving certificates, stocks, bonds, or any other kind of asset. I further certified that I have not disposed of any property worth more than $2,000 in the last two year period.

I certify that all of the information included in this application is true and correct.

Applicant Name

Signature

 

Date

The following documentation should be included with this form:

ｸSigned Release of Information form

ｸBirth certificate (or verification of birthplace/date from Social Security, proof of application from HSA/DSS for copy of birth certificate, or driver’s license)

ｸAward letter for SSI/SSDI from Social Security Administration, budget from HSA/DSS, or other documentation of income (pay stubs, etc.)

ｸDocumentation of disability (letter from treatment provider, primary care provider, signed by professional qualified to make the diagnosis)

ｸCertification of Homelessness

How to Edit Form Pas 106H Online for Free

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Concentrate when filling out this form. Ensure every single blank is filled out properly.

1. Fill out your shelter intake form with a group of major blanks. Consider all of the required information and make certain absolutely nothing is omitted!

Ways to prepare homeless shelter intake document step 1

2. Once the last section is completed, you're ready to add the necessary particulars in Note If the participant came from, Certificate of Homelessness is, Can the person be considered, Yes documentation is attached No, What is the qualifying disability, Is documentation from a, Yes No, Other Household Members Please, Relationship, Name, Date of Birth, Age, and Social Security Number so that you can progress to the third stage.

Completing segment 2 of homeless shelter intake document

As to Yes No and Certificate of Homelessness is, make certain you don't make any errors in this current part. Both of these are the most significant fields in the file.

3. This 3rd step is usually rather simple, PASH Revised - each one of these blanks will need to be filled out here.

Step number 3 in filling in homeless shelter intake document

4. All set to start working on the next portion! Here you've got all of these Please place the total number of, Hispanic or Latino NonHispanic or, Demographics Ethnicity Race, Mental Illness Alcohol Abuse Drug, and Developmental Disability Physical blanks to complete.

Filling out segment 4 in homeless shelter intake document

5. As a final point, the following final part is precisely what you should wrap up prior to using the form. The blanks in this instance are the following: Total Household Monthly Income, Supplemental Security Income SSI, Social Security Disability Income, Temporary Aid to Needy Families, Child Support, Veterans Benefits, Employment Income, Unemployment Income, Medicare, Medicaid Food Stamps, Other please specify, and No Financial Resources.

Filling out segment 5 in homeless shelter intake document

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