Community Housing Guide Tenant Screening Individual’s Name:
Form Date (10/2019) Page 1 of 15
COMMUNITY HOUSING GUIDE
TENANT SCREENING
Instructions: Please complete this tenant screening in as much detail as possible. The information from the tenant
screening will be used to develop a Housing Road Map with the individual and the person-centered planning team. If a
question does not apply to the individual, write “N/A.” Do not leave blanks.
A. INDIVIDUAL’S CONTACT INFORMATION
NAME (first, middle, last name)
DATE OF BIRTH (MM/DD/YYYY) TELEPHONE NUMBER (###-###-####)
CURRENT PHYSICAL ADDRESS (street address) CITY STATE ZIP CODE
MAILING ADDRESS if different (street address) CITY STATE ZIP CODE
B. LEGAL GUARDIAN’S OR SUBSTITUTE DECISION MAKER’S CONTACT INFORMATION
NAME (first and last name)
TELEPHONE NUMBER (###-###-####) EMAIL ADDRESS
MAILING ADDRESS (street address) CITY STATE ZIP CODE
RELATIONSHIP (guardian, conservator, power of attorney, authorized representative, etc.)
C. EMERGENCY CONTACT’S INFORMATION (if same as legal guardian or substitute decision maker, write “same as above” in NAME)
NAME (first and last name)
TELEPHONE NUMBER (###-###-####) EMAIL ADDRESS
MAILING ADDRESS (street address) CITY STATE ZIP CODE
RELATIONSHIP (guardian, conservator, power of attorney, authorized representative, parent, grandparent, sibling, friend, etc.)
D. SUPPORT COORDINATOR/CSB CONTRACTED CASE MANAGER’S CONTACT INFORMATION
NAME (first, last name)
REFERRAL DATE DEVELOPMENTAL SERVICES REGION
AGENCY NAME/COMMUNITY SERVICES BOARD (If you contract with a CSB to provide support
coordination, list your organization’s name and the name of the CSB that you contract with to provide case
management services.)
ORGANIZATIONAL ROLE
CSB Support Coordinator
CSB Contracted Case Manager
MAILING ADDRESS (street or P.O. Box) CITY STATE ZIP CODE
TELEPHONE NUMBER (###-###-####)
FAX NUMBER (###-###-####) EMAIL ADDRESS
Community Housing Guide Tenant Screening Individual’s Name:
Form Date (10/2019) Page 2 of 15
E. HOUSING PREFERENCES
E.1 Describe the place you want to live in a few sentences. What does it look like?
E.2 Name three communities or neighborhoods where you would like to live.
Community/Neighborhood Name
City or
c
ounty in which the
community/neighborhood is located
1)
2)
3)
E.3 What type of housing do you prefer?
low-rise apartment building (1-4 floors) single family detached home
mid-rise apartment building (5-10 floors) single family attached home
high-rise apartment building (over 10 floors) Other:
E.4 What housing features are important to and for you?
Place an “X” by the housing features that are important to
important for
you
.
“Important
t
o”
means
the
individual prefers this feature. “Important For” means the feature is critical to your health and safety. Note: “Near”
means within walking distance or no more than a 30 minute ride on public transportation.
IMPORTANT TO
IMPORTANT FOR
Walking distance to public transportation
Walking distance to accessible public transportation
Walking distance to shopping and banking
Near doctor or health care providers
Near employment
Near supportive services
Near family and friends
Familiar neighborhood
Well-lit sidewalks
Parking on site
Secured building entrance
Property management on site
Space or storage for medical or adaptive equipment
Room for a live-in caregiver
Housing where pets are allowed
Housing where pets are prohibited
Housing where smoking is allowed
Housing where smoking is prohibited
Private bathroom
Electric appliances
Washer and dryer in the apartment
Washer and dryer in the building
Ground floor unit
No-step entry to building and unit
Accessible unit
Other:
Community Housing Guide Tenant Screening Individual’s Name:
Form Date (10/2019) Page 3 of 15
E.5. With whom do you want to live?
List all persons who will reside with you and be on your lease. Include birth dates, relationship, and student status. List each person’s gross
monthly income. Indicate whether each agrees to make his/her income and resources available to the household (exclude live-in aides).
F. HOUSING STRENGTHS
F.1 What activities around the house can you do independently or with minimal support?
F.2 What technology do you use that will help you live more independently?
F.3 Who can help you make the move to your own home? What tasks can they do? (e.g., “My parents can help me look for
apartments” or “My brother can help me pack and move my belongings to my new place”)
F.4 What resources can you or your family provide to support your move to your own home? (e.g., “I have a Special Needs Trust or
ABLE Account that can pay for my security deposit” or “My aunt is giving me a bed and dining set”)
First and last name Date of birth Relationship (self, spouse,
sibling, child, unrelated
friend, live-in aide)
Full-time
student?
(Yes or No)
Gross monthly
income (include
wages, benefits,
pensions, etc.)
Agrees to make income
and resources available
to household? (Yes or
No)
Individual/Self
Community Housing Guide Tenant Screening Individual’s Name:
Form Date (10/2019) Page 4 of 15
G. PREPARING FOR INDEPENDENT LIVING
G.1 What will my income and expenses be when I live in my own place?
Use this independent living budget to calculate what your income and expenses will be when you rent your own rental housing. Under
Income, remember to account for changes in monthly benefits that may occur if you move from your family’s home to your own
home. Under Fixed Expenses, if you have applied for a rent subsidy, estimate the subsidized amount you will pay toward rent and
utilities (e.g., approximately 30-40% of monthly income toward rent and utilities, NOT including phone, internet and cable). If you are
not applying for a rent subsidy, estimate the full cost of rent and utilities for the unit size needed. Under Flexible Expenses, be realistic
about your wants and needs. Divide up expenses to be shared among housemates, and include only your share in this budget. If
certain expenses will be fully paid by another source (e.g., a Special Needs Trust, ABLE Account, family, etc.), provide the name of the
source in the “Alternative Source” column and do not list an amount in the “Cost” column.
Monthly Income Monthly Flexible Expense Cost Alternative
Source
Earned Income
$
Savings
$
SSI
$
Groceries
$
SSDI
$
Eating Out
$
SSA
$
Entertainment/Hobbies
$
Pension
$
Laundry
$
Other
$
Cleaning/Household Supplies
$
Other
$
Clothes/Personal Care Supplies
$
TOTAL INCOME [A]
$
Gasoline/Bus/Taxi
$
Newspaper/Magazines
$
Monthly Fixed
Expenses
Cost
Alternative
Source
Alcohol/Cigarettes
$
Rent*
$
Tuition/Books
$
Electric
$
Barber/Beautician
$
Gas/Oil
$
Auto Maintenance
$
Water/Sewer
$
Doctor/Dentist
$
Home Phone
$
Pets
$
Cell Phone
$
Parking
$
Internet Service
$
Repairs
$
Trash Pickup
$
TOTAL FLEXIBLE [D] $
Cable
$
Medical Insurance
$
FIXED [B] $
Auto Insurance
$
DEBT [C] $
Life Insurance
$
FLEXIBLE [D] $
Renters Insurance
$
TOTAL EXPENSES [E ] $
Child
Support/Alimony
$
Child Care
$
Subtract Expenses from Income (A-E)
Other
$
TOTAL INCOME [A] $
TOTAL FIXED [B]
$
TOTAL EXPENSES [E] $
DIFFERENCE + OR - $
Monthly Debt
Payments
Cost Alternative Source
Notes
Installment Loans
$
Automobile Loan
$
Credit Card Payments
$
TOTAL DEBT [C]
$
Community Housing Guide Tenant Screening Individual’s Name:
Form Date (10/2019) Page 5 of 15
G.2 What furniture and household supplies do I have and what will I need in my new place?
Put an “X” by the items you have or you can get at no cost (and write a note about where you can get them). Put a dollar
estimate under each item you need.
ITEM
I HAVE THIS
(place an “X” next to
the items you have)
I NEED THIS
(insert estimated cost
for each item you need)
I CAN GET THIS FROM…
(write in where you will get the item,
e.g., parents, friend, recycling club, etc.)
Furniture
Bed
$
Mattress and box spring
$
Nightstand
$
Chest of drawers
$
Couch
$
Chairs
$
Coffee table
$
Bookshelves
$
Entertainment center
$
Television
$
Dining table and chairs
$
Lamps
$
TOTAL COST OF FURNITURE I NEED
$
ITEM
I HAVE THIS
I NEED THIS
I CAN GET THIS FROM…
Household Supplies
Sheet sets (2-3 sets)
$
Comforter or blanket
$
Pillows
$
Pillowcases
$
Mattress pad
$
Mattress protector
$
Curtains
$
Curtain rods
$
Area rug
$
Alarm clock
$
Mirror
$
Fan
$
Sheet sets (2-3 sets)
$
Kitchen Supplies
Coffeemaker $
Microwave $
Toaster/toaster oven $
Can opener $
Cookware (2 covered
saucepans, fry pan)
$
Community Housing Guide Tenant Screening Individual’s Name:
Form Date (10/2019) Page 6 of 15
ITEM
I HAVE THIS
I NEED THIS
I CAN GET THIS FROM…
Kitchen Supplies (continued)
Chef's knife $
Paring knife $
Cookie sheet $
Pyrex/Corning set $
Cutting Board $
Food storage container set $
Canister set $
Measuring cups $
Measuring spoons $
Bottle opener $
Spatula $
Ladle
$
Paper towel holder
$
Dish towels
$
Pot holders
$
Dish drainer
$
Large mixing bowl
$
4 sets of plates, bowls, mugs
$
4 sets of forks, knives, spoons
$
Salt and pepper set
$
Tea kettle
$
Coffee mugs
$
Basic condiments (oil, vinegar,
ketchup, mustard, mayo)
$
Basic seasonings (salt, pepper,
garlic powder, etc.)
$
Bathroom Supplies
Towels (2-3 sets)
$
Tub mat
$
Rugs/bath mat
$
Shower curtain
$
Shower curtain rings
$
Shower curtain liner
$
Shower caddy
$
Hair dryer
$
Toothbrush
$
Toothbrush holder
$
Soap dish
$
Tumbler
$
Wastebasket
$
Bath scale
$
Community Housing Guide Tenant Screening Individual’s Name:
Form Date (10/2019) Page 7 of 15
ITEM
I HAVE THIS
I NEED THIS
I CAN GET THIS FROM…
Kitchen Supplies (continued)
Toilet brush
$
Hamper
$
Plunger
$
Toilet paper
$
Tissues
$
Housecleaning Supplies
Vacuum
$
Mop and bucket
$
Garbage can and bags
$
Iron
$
Ironing board
$
Laundry basket
$
Step stool
$
Broom and dust pan
$
Laundry soap and fabric
softener
$
Kitchen and bathroom cleaning
solution, glass cleaning solution
$
Organizing Supplies
Hangers
$
Surge protectors
$
Extension cords
$
Flashlight
$
First aid kit
$
Batteries
$
Storage boxes
$
Hooks
$
Light bulbs
$
Bulletin board
$
Lamps
$
Picture frames
$
TOTAL COST OF HOUSEHOLD SUPPLIES I NEED
$
G.2 What resources can I use to pay for the costs of moving to a new place?
Use this Moving Budget to identify the resources you have to support your move and the costs to make your move.
RESOURCES
Special needs trust $
ABLE account $
Security deposit reimbursement (if renting now) $
Monetary gifts from friends or family $
Savings $
Other $
Community Housing Guide Tenant Screening Individual’s Name:
Form Date (10/2019) Page 8 of 15
Total Income and Assets (1) $
MOVING EXPENSES Cost
Old House
Repairs And maintenance $
Cleaning $
Final power bill $
Final phone bill $
Final water and sewer bill $
Final Internet bill $
Final gas bill $
Final cable bill $
Boxes $
Moving van rental $
Gasoline $
Moving company quote $
Temporary accommodation (e.g., hotel) $
Storage unit $
Transit (moving) insurance $
Tape, bubble wrap, and/or markers $
Other (describe):___________________________________ $
Total Moving Expenses from Old House (2) $
New House Cost
Application fee $
Holding fee $
Security deposit $
First month’s rent $
Amenity fee (e.g., pool pass) $
Parking fee $
Pet deposit $
Phone deposit $
Electric deposit $
Electric connection fee $
Water deposit $
Water connection fee $
Internet deposit $
Cable connection fee $
Gas deposit $
Gas connection cee $
Accessibility modifications $
New furniture (see total on page 4) $
New household supplies (see total on page 6) $
Other (describe):___________________________________ $
Total moving expenses to new house (3) $
Total income for moving (1) $
Total expenses for moving (2+3) $
Community Housing Guide Tenant Screening Individual’s Name:
Form Date (10/2019) Page 9 of 15
Surplus / Deficit $
G.3: What supports and services do you need to live in your own home? Who will provide these supports?
Make a calendar of supports you need on weekdays and weekends
from
when you wake up to
when you go to sleep. List
each
activity you need help to do, the kind of help you need, who helps you now, and who will help you when you live in your own home.
WEEKDAYS
Time period Activity Help needed Who provides help
now
Who will provide help
when person lives in
his/her own home?
Example:
6:30 – 7:00 am
Wake up and shower Reminder to shower; physical
assistance to wash my back
Mom Joe, my personal care
attendant
WEEKENDS
Time period Activity Help needed Who provides help
now
Who will provide help
when person lives in
his/her own home?
Example:
8:30– 9:00 am
Wake up and shower
Community Housing Guide Tenant Screening Individual’s Name:
Form Date (10/2019) Page 10 of 15
H. HOUSING BARRIERS
H.1 Which housing eligibility documents do you have? Which documents do you need? Place an “X” in the appropriate
column.
HAVE
NEED
Social Security card
Government issued photo ID (e.g., passport, state issued ID, military ID)
Birth certificate or proof of citizenship/permanent legal residency in the U.S.
Proof of income letter from Social Security
Current bank statement(s)
Other income and asset documentation
H.2. Have you ever had trouble with any of the following issues in housing? Place an “X” in the appropriate column.
YES
NO
paying rent on time?
keeping up with utility bills?
visitors/guest problems?
landlord/neighbor relationships?
clutter/home maintenance?
being evicted?
H.3 If you have been evicted from housing, list the dates and reasons (e.g., nonpayment of rent, damage to unit,
unauthorized occupants, etc.). If you do not have an eviction history, write “n/a.”
Date
Reason
H.4 Do you currently owe money to any of the following companies? Place an “X” in the appropriate column.
YES
NO
a previous landlord (e.g., for unpaid rent, fees or damages)?
a public housing agency (e.g., for rent or other amounts)?
a utility
company (e.g., for unpaid utility bills or fees)?
H.5 Describe any arrests, charges or convictions you have had, including when they occurred and what happened.
Community Housing Guide Tenant Screening Individual’s Name:
Form Date (10/2019) Page 11 of 15
H.6 Do you owe anyone money? Go to www.annualcreditreport.com and pull your credit report. Indicate whether the
credit report shows any outstanding debts or collections for the following expenses.
Type of expense Name of company owed Amount due In collections? (Yes/No)
Housing
Utilities
Telephone
Child
support
Car
Credit
card
Medical
Other:
H.7 Have you ever filed for bankruptcy? YES NO If yes, date:
I. HOUSING HISTORY
I.1. Describe your current living situation in terms of the type of residence, rent, subsidy and leasing arrangements.
Type of
residence
(e.g., training center; ICF/DD; group home; family home; commercial rental
property; public housing; or unit owned by service provider, private owner, relative, etc.)
Property
name
Owner
or
landlord name
Owner
or
landlord phone
Does the individual have a
lease in his/her name?
(Yes/No)
If YES, what date does the
lease end?
If there is no lease, has
individual been given a
date he/she must leave
this housing? (Yes/No)
If YES, what date must
individual leave this housing?
Why must individual leave
this housing?
Is the individual charged
rent for this living
situation? (Yes/No)
If YES, how much is the rent?
(e.g., $X/month)
Who charges the individual
rent? (e.g., landlord, family,
service provider)
Is the housing
subsidized? (Yes/No)
If subsidized, is subsidy
tenant- or project-based?
Does a representative
payee manage the
individual’s rent? (Yes/No)
OK to serve as rent
reference? (Yes/No)
I.2 For each setting in which you previously lived, list the dates of residence. Describe what worked/didn’t work about each setting.
Type of residential setting Dates of
residence
What about this setting
worked for you?
What about this setting didn’t
work for you?
State Training Center
Skilled Nursing Facility
State Psychiatric Hospital
Residential Substance Abuse Treatment Program
Private Intermediate Care Facility (ICF/DD)
Assisted Living Facility
Community Housing Guide Tenant Screening Individual’s Name:
Form Date (10/2019) Page 12 of 15
Group Home for adults with DD
Type of residential setting Dates of
residence
What about this setting
worked for you?
What about this setting didn’t
work for you?
Group home for adults with mental illness
Family home (e.g., with parent, guardian, sibling)
Emergency shelter for homeless
Transitional housing for homeless
Permanent supportive housing for homeless
Jail, prison or juvenile detention facility
Residential school
Hotel or motel
Foster care home or foster care
Street or place not meant for human habitation
Other (describe):
I.3 Provide a summary of your experience living in rental housing. If you have not lived in rental housing, put “N/A” in the first box
and skip to Section I.4.
I.
List the most recent rental housing arrangement first and work backwards. Do not include your current living situation or the
residential settings in the “Residential Experiences” section above (e.g., family home, group home, etc.). Note: In “subsidized”
housing, your rent payment is based on a percentage of your income. A “tenant-based” subsidy is a subsidy you can take to any
landlord who will accept it. A “project-based” subsidy is attached to and remains with a specific unit at a property.
a.
Property
name
Owner or
l
andlord
n
ame
Owner or
l
andlord
p
hone
Dates of
r
esidence
City/
s
tate of
r
esidence
Type of
r
esidence
(check one)
Commercial apartment rental
Privately owned housing unit
Public housing
Housing unit owned/leased by
service provider
Unit owned by a relative
Other______________________
OK to serve as rent
reference? (Yes/No)
Was the individual
charged rent?
(Yes/No)
How much was the rent?
(e.g., $X/month)
Did the individual
have a lease?
(Yes/No/Don’t Know)
Reason for Leaving
Was housing
subsidized? (Yes/No)
If subsidized, was subsidy
tenant- or project-based?
Community Housing Guide Tenant Screening Individual’s Name:
Form Date (10/2019) Page 13 of 15
b.
Property
n
ame
Owner or
l
andlord
n
ame
Owner or
l
andlord
p
hone
Dates of
r
esidence
City/
s
tate of
r
esidence
Type of
r
esidence
(check one)
Commercial apartment rental
Privately owned housing unit
Public housing
Housing unit owned/leased by
service provider
Unit owned by a relative
Other______________________
OK to serve as rent
reference? (Yes/No)
Was the individual
charged rent?
(Yes/No)
How much was the rent?
(e.g., $X/month)
Did the individual
have a lease?
(Yes/No/Don’t Know)
Reason for Leaving
Was housing
subsidized? (Yes/No)
If subsidized, was subsidy
tenant- or project-based?
I.4: Where do you work? If you are not currently employed, put “No” in the box for question A. Leave the remaining
boxes blank and skip to question B. If you are not currently in supported employment, vocational training or vocational
rehabilitation, put “No” in the box for question B. Leave the remaining boxes blank and go to Section J.
Employers
provide verification of income for rental applications and can s
erve as positive ren
tal references.
Consider
asking if you can list your employer as a reference on rental applications or if your employer would write a reference
letter. Participation in supported employment and vocational training may impact eligibility and/or amount of
assistance received in certain rental assistance and affordable housing programs.
A.
Are
y
ou
c
urrently
e
mployed?
(Yes/No)
Hours
p
er
w
eek
Name of
e
mployer
Type of
w
ork
(full time, part
time, temporary, seasonal)
Street
a
ddress
City
State
Zip
c
ode
Supervisor
n
ame
Phone
n
umber
OK to
contact
for rent reference?
(Yes/No)
Email
B.
Are
y
ou
c
urrently in
supported employment,
vocational training or vocational
rehabilitation (e.g., DARS)?
(Yes/No)
Hours
p
er
w
eek
Name of
p
rogram
Program
c
ontact
p
erson
Program
p
hone
n
umber
Email
Community Housing Guide Tenant Screening Individual’s Name:
Form Date (10/2019) Page 14 of 15
J. HOUSING NEEDS
J.1 My housing must be located close to (describe what you want to live near, such as your job, school, family,
shopping, services, hospital, etc.):
J.2 My housing must be located away from (describe what you do not want to live near, such as major intersections
with high speed traffic, people who have been a negative influence in the past, areas with lots of street noise, etc.)
J.3 What safety and security features in housing are important for you (e.g., electric instead of gas appliances, secure
building entry system)?
J.4 What accessibility features in housing are important for you (e.g., roll-in shower, wide doorways, no step entry)?
J.5 What reasonable accommodations will you need (e.g., approval to pay rent in the middle of the month, parking
space for visiting support staff, emotional support animal)?
Community Housing Guide Tenant Screening Individual’s Name:
Form Date (10/2019) Page 15 of 15
K. REVIEW OF ELIGIBILITY FOR HOUSING OPTIONS
Based on the information provided, your Community Housing Guide will complete this chart and identify the housing resources for
which you may be eligible. If the resource is available AND you (1) are in the target population, (2) are income eligible and (3) do
not meet any major denial criteria, the housing resource may be an option for you. Some housing resources may be available in
your preferred community but they may have a waitlist. Waitlists may be open or closed. This chart will help you prioritize which
housing resources to pursue.
Housing resources Available where
you want to live?
(Yes/No)
Do you meet
categorical
eligibility?
(Yes/No)
Are you income
eligible, based
on budget?
(Yes/No)
Do you meet a
major denial
criterion?
(Yes/No)
Does the housing
resource have a
waitlist? (Yes/No)
Is the waitlist
open?
(Yes/No)
1. HOUSING RESOURCES FOR SETTLEMENT AGREEMENT TARGET POPULATION
Housing Choice
Voucher – Special
Needs Preference
State Rental
Assistance
Program
Low Income
Housing Tax Credit
Properties –
Leasing Preference
2. HOUSING RESOURCES FOR LOW/MODERATE INCOME HOUSEHOLDS
Local Housing
Choice Voucher
Program
Public Housing
Project Based
Voucher Program
Low Income
Housing Tax Credit
Program
Rental Affordable
Dwelling Units
Rural Development
515 Housing
Section 8
Federally Assisted
Housing
Other:
Other: