Sample MOU and Certifications
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1 Attachment 2 Sample MOU Template Memorandum of Understanding [** This sample document demonstrates the Memorandum of Understanding requirements for the administration Emergency Housing Voucher. Unless otherwise noted, all elements are required. **] This Memorandum of Understanding (MOU) has been created and entered into on [** Insert execution date. **]. [PHA Name and Address] [CoC Name and Address] I. Introduction and Goals (the following elements, listed in a. – c., are required elements of the MOU): a. PHA and CoC’s commitment to administering the EHVs in accordance with all program requirements. b. PHA goals and standards of success in administering the program. c. Identification of staff position at the PHA and CoC who will serve as the lead EHV liaisons. Lead HCV Liaison: [Name and title of PHA staff position] Responsibilities of the PHA EHV liaison [**Optional**]. [Name and title of CoC staff position] Responsibilities of the CoC EHV liaison [**Optional**]. II. Define the populations eligible for EHV assistance to be referred by CoC. 2 III. Services to be provided to eligible EHV families 1. List the services to be provided to assist individuals and families have success in the program and who will provide them. [**The following services are listed for example purposes. **] 1. Partnering service providers will support individuals and families in completing applications and obtaining necessary supporting documentation to support referrals and applications for assistance; while aiding households in addressing barriers. 2. Partnering service providers will support PHAs in ensuring appointment notifications to eligible individuals and families and will assist eligible households in getting to meetings with the PHA. 3. PHAs will establish windows of time for EHV applicants to complete intake interviews for EHV. 4. Partnering service providers will provide housing search assistance for eligible individuals and families. 5. Partnering service providers will provide counseling on compliance with rental lease requirements. 6. Partnering service providers will assess individuals and families who may require referrals for assistance on security deposits, utility hook-up fees, and utility deposits. 7. Partnering service providers will assess and refer individuals and families to benefits and supportive services, where applicable. IV. PHA Roles and Responsibilities [**The following responsibilities are listed for example purposes. **] 1. Coordinate and consult with the CoC in developing the services and assistance to be offered under the EHV services fee. 2. Accept direct referrals for eligible individuals and families through the CoC Coordinated Entry System. 3. Commit a sufficient number of staff and necessary resources to ensure that the application, certification, and voucher issuance processes are completed in a timely manner. 4. Commit a sufficient number of staff and resources to ensure that inspections of units are completed in a timely manner. 5. Designate a staff to serve as the lead EHV liaison. 3 6. Comply with the provisions of this MOU. V. CoC Roles and Responsibilities [**The following responsibilities are listed for example purposes. **] 1. Designate and maintain a lead EHV liaison to communicate with the PHA. 2. Refer eligible individuals and families to PHA using the community’s coordinated entry system. 3. Support eligible individuals and households in completing and applying for supportive documentation to accompany admissions application to the PHA (i.e. self-certifications, birth certificate, social security card, etc.). 4. Attend EHV participant briefings when needed. 5. Assess all households referred for EHV for mainstream benefits and supportive services available to support eligible individuals and families through their transition. 6. Identify and provide supportive services to EHV families. (While EHV participants are not required to participate in services, the CoC should assure that services are available and accessible.) 7. Comply with the provisions of this MOU. VI. Third Party Entity Roles Responsibilities [**The following responsibilities are listed for example purposes. **] 1. Describe how the State, local, philanthropic, faith-based organizations, Victim Service Providers or CoC recipients it designates will fulfill each of the following responsibilities: a. Outline resource and/or service being provided in support of the community’s EHV Program. Commit a sufficient number of staff and necessary resources to ensure that the application, certification and voucher issuance processes are completed in a timely manner. b. Comply with the provisions of this MOU. VII. Program Evaluation The PHA, and CoC or designated CoC recipient agree to cooperate with HUD, provide requested data to HUD or HUD-approved contractor delegated the responsibility of program evaluation protocols established by HUD or HUD-approved contractor, including possible random 4 assignment procedures. [Signed and dated by the official representatives of the PHA, CoC, CoC Contractor organization (if applicable), and third-party entities (if applicable.] Signed by ________________________________________ ___________________ Executive Director, PHA Date _______________________________________ ___________________ CoC Executive Director Date 5 Attachment 3 - Example of a Homeless Provider’s Certification Emergency Housing Voucher (EHV) HOMELESS CERTIFICATION EHV Applicant Name: ______________________________________________ Household without dependent children (complete one form for each adult in the household) Household with dependent children (complete one form for household) Number of persons in the household: _________ This is to certify that the above named individual or household meets the following criteria based on the check mark, other indicated information, and signature indicating their current living situation- Check only one box and complete only that section Living Situation: place not meant for human habitation (e.g., cars, parks, abandoned buildings, streets/sidewalks) The person(s) named above is/are currently living in (or, if currently in hospital or other institution, was living in immediately prior to hospital/institution admission) a public or private place not designed for, or ordinarily used as a regular sleeping accommodation for human beings, including a car, park, abandoned building, bus station, airport, or camp ground. Description of current living situation: _____________________________________________________________________________________ _____________________________________________________________________________________ ______________________________________________ Homeless Street Outreach Program Name:_________________________________________________________________________ This certifying agency must be recognized by the local Continuum of Care (CoC) as an agency that has a program designed to serve persons living on the street or other places not meant for human habitation. Examples may be street outreach workers, day shelters, soup kitchens, Health Care for the Homeless sites, etc. Authorized Agency Representative Signature: _________________________________________ Date: ______________________ 6 Living Situation: Emergency Shelter The person(s) named above is/are currently living in (or, if currently in hospital or other institution, was living in immediately prior to hospital/institution admission) a supervised publicly or privately operated shelter as follows: Emergency Shelter Program Name: _____________________________________________________________ This emergency shelter must appear on the CoC’s Housing Inventory Chart submitted as part of the most recent CoC Homeless Assistance application to HUD or otherwise be recognized by the CoC as part of the CoC inventory (e.g., newly established Emergency Shelter). Authorized Agency Representative Signature: _________________________________________ Date: ______________________ Living Situation: Recently Homeless The person(s) named above is/are currently receiving financial and supportive services for persons who are homeless. Loss of such assistance would result in a return to homelessness (ex. Households in Rapid Rehousing Programs, residents of Permanent Supportive Housing Programs participating in Moving On, etc.) Authorized Agency Representative Signature: ____________________________________________________________ This referring agency must appear on the CoC’s Housing Inventory Chart submitted as part of the most recent CoC Homeless Assistance application to HUD or otherwise be recognized by the CoC as part of the CoC inventory. Immediately prior to entering the household’s current living situation, the person(s) named above was/were residing in: emergency shelter OR a place unfit for human habitation Authorized Agency Representative Signature: _________________________________________ Date: ______________________ 7 Attachment #4 Example of a Victim Services Provider’s Certification Emergency Housing Voucher (EHV) SAMPLE HUMAN TRAFFICKING CERTIFICATION Purpose of Form: The Victims of Trafficking and Violence Protection Act of 2000 provides assistance to victims of trafficking making housing, educational health care, job training and other Federally-funded social service programs available to assist victims in rebuilding their lives. Use of This Optional Form: In response to this request, the service provider may complete this form and submit it to the Public Housing Agency (PHA) to certify eligibility for EHV assistance. Confidentiality: All information provided to the service provider concerning the incident(s) of human trafficking shall be kept confidential and such details shall not be entered into any shared database. Employees of the PHA will not have access to these details, and such employees may not disclose this information to any other entity or individual, except to the extent that disclosure is: (i) consented to by you in writing in a time-limited release; (ii) required for use in an eviction proceeding or hearing regarding termination of assistance; or (iii) otherwise required by applicable law. TO BE COMPLETED ON BEHALF OF HUMAN TRAFFICKING SURVIVOR EHV Applicant Name: ______________________________________________ This is to certify that the above named individual or household meets the definition for persons who are fleeing or attempting to flee human trafficking under section 107(b) of the Trafficking Victims Protection Act of 2000. Immediately prior to entering the household’s current living situation, the person(s) named above was/were residing in: _____________________________________________________________________________________ _______________________________________________________________________ 8 This is to certify that the information provided on this form is true and correct to the best of my knowledge and recollection, and that the individual(s) named above is/has been a victim of human trafficking. I acknowledge that submission of false information could jeopardize program eligibility and could be the basis for denial of admission, termination of assistance, or eviction. Authorized Agency Representative Signature: ___________________ Date: __________________