Ending Veteran Homelessness Initiative
1. Which of the following best describes your entity: *
Nonprofit Housing Program
Landlord or Property Management
(untitled)
2. Are you able to make a committment to provide any of the following?
Connections with Landlords
Housing Units
Security Deposit Funds (please specify amount committed)
Move-in Kits (toiletries, bedding, cleaning supplies, etc.) (please specify number
of move-in kits or value amount)
3. Agency Name
4. Program Name
Please indicate the name of your project exactly as it is referred to by your main funding
source.
5. Primary Program Contact
First Name
Last Name
Title
Street Address
Apt/Suite/Office
City
State
Zip
Email Address
Phone Number (000-000-0000)
6. Project Site Information
For Scattered Sites: please indicate zip codes of all sites
For Project Address: please indicate full address including zip code
Project (enter zip code or neighborhoods)
Scattered Sites (enter zip codes or neighborhoods)
Domestic Violence Provider - Address Confidential
7. Which of the following best describes your project housing type?
Permanent Housing with Short-term Supports (PHwSS)
Supportive Services for Veteran Families (SSVF)
Rapid Re-Housing (RRH)
Permanent Supportive Housing (PSH)
Safe Haven (SH)
Low-Income Housing Trust Fund (LIHTF)
Chicago Housing Authority - Property Rental Assistance (CHA-PRA)
Other (please specify)
8. Unit Configuration
0/1BR
Total
Number
of Units
Number
of Units
for
Single
Males
Number
of Units
for
Single
Females
Number
of Units
for
Single
Males or
Females
Number
of Units
for
Families
with
Children
2BR
3BR
4BR
5BR
6BR
Other
9. Target Populations (please indicate number of units that are currently dedicated to specific
populations)
0/1BR
2BR
3BR
4BR
5BR
6BR
Other
Not
Dedicated
to Target
Population
Veterans
Chronic
Homeless
Survivors
of
Domestic
Violence
Persons
with
HIV/AIDS
Persons
with
Severe
Mental
Illness
10. How many of these units do you expect to be made available to the Ending Veteran
Homelessness Initiative by December 2015?
0/1BR
Expected
Available
Units
Committed to
the Ending
Veteran
Homelessness
Initiative
2BR
3BR
4BR
5BR
6BR
Other
11. Landlord or Property Manager Name
(untitled)
12. Primary Property Contact
First Name
Last Name
Title
Street Address
Apt/Suite/Office
City
State
Email Address
Phone Number (000-000-0000)
Zip
13. Site Address(es)
For Scattered Sites: please indicate zip codes of all sites
Single Site Property (enter zip code)
Scattered Sites (enter zip codes)
14. How many of these units are you committing to the Veterans Initiative by December 2015?
0/1BR
2BR
3BR
4BR
5BR
6BR
Other
Expected
Available
Units
Committed
to the
Veterans
Initiative
15. What is the typical rent amounts of the units are you committing to the Veterans Initiative?
0/1BR
Expected
Available
Units
Committed
to the
Veterans
Initiative
2BR
3BR
4BR
5BR
6BR
Other
16. Is there is a security deposit/move-in fee required?
Yes (enter the amount of the required security deposit and/or move-in fee here)
*
No
17. Unit Configuration (Please include all units for the properties listed above)
0/1BR
Total
Number
of Units
Number
of Units
for
Single
Males
Number
of Units
for
Single
Females
Number
of Units
for
Single
Males or
Females
Number
of Units
for
Families
with
Children
2BR
3BR
4BR
5BR
6BR
Other
18. Do you require a background check for tenancy in these units?
No
Yes (please list any factors that would prevent tenancy for these units)
19. Are utilites included in the rent for these units?
Yes
No
20. Is a formal leased signed for these units?
Yes
No
21. Do these units receive any of the following funding?
HUD Emergency Solutions Grant Program (ESG)
HUD Continuum of Care Program (CoC)
HUD Section 8 Moderate Rehabilitation Single-Room Occupancy program
(SRO), including grants formerly funded under McKinney-Vento but renewed under
Section 8
Department of Veteran Affairs (VA)
Other: Please Specify