3 14-21 days POTENTIAL BARRIERS AND VULNERABILITIES (May impact ability to quickly secure housing and resolve literal homelessness independently if household is not assisted and becomes literally homeless) Current household income is $0 (i.e., not employed, not receiving cash benefits, no 5 other current income) Annual Household Gross Income Amount (select only one) 4 0-14% of Area Median Income (AMI) for household size 3 15-30% of AMI for household size Sudden and significant decrease in cash income (employment and/or cash benefits) 3 AND/OR unavoidable increase in non-discretionary expenses (e.g., rent or medical expenses) in the past 6 months Major change in household composition (e.g., death of family member, 3 separation/divorce from adult partner, birth of new child) in the past 12 months Rental evictions within the past 7 years (select only one) [Staff Note: Only include formal eviction actions (i.e., Notice to Quit) taken by a landlord due to lease non-compliance and that ultimately resulted in loss of rental housing.] 5 4 or more prior rental evictions 4 2-3 prior rental evictions 3 1 prior rental eviction Currently at risk of losing a tenant-based housing subsidy or housing in a subsidized 3 building or unit History of Literal Homelessness (street/shelter/transitional housing) (select only one) 5 4 or more or total of at least 12 months in past three years 4 2-3 times in past three years 3 1 time in past three years Head of household with disabling condition (physical health, mental health, 3 substance use) that directly affects ability to secure/maintain housing Criminal record for arson, drug dealing or manufacture, or felony offense against 4 persons or property 5 Registered sex offender 3 At least one dependent child under age 6 3 Single parent with minor child(ren) 3 Household size of 5 or more requiring at least 3 bedrooms (due to age/gender mix) POLICY PRIORITIES 3 Any Veteran in household served in Iraq or Afghanistan
14-21 days 3 POTENTIAL BARRIERS AND VULNERABILITIES (May impact ability to quickly secure housing and resolve literal homelessness independently if household is not assisted and becomes literally homeless) Current household income is $0 (i.e., not employed, not receiving cash benefits, no other current income) 5 Annual Household Gross Income Amount (select only one) 0-14% of Area Median Income (AMI) for household size 4 15-30% of AMI for household size 3 Sudden and significant decrease in cash income (employment and/or cash benefits) AND/OR unavoidable increase in non-discretionary expenses (e.g., rent or medical expenses) in the past 6 months 3 Major change in household composition (e.g., death of family member, separation/divorce from adult partner, birth of new child) in the past 12 months 3 Rental evictions within the past 7 years (select only one) [Staff Note: Only include formal eviction actions (i.e., Notice to Quit) taken by a landlord due to lease non-compliance and that ultimately resulted in loss of rental housing.] 4 or more prior rental evictions 5 2-3 prior rental evictions 4 1 prior rental eviction 3 Currently at risk of losing a tenant-based housing subsidy or housing in a subsidized building or unit 3 History of Literal Homelessness (street/shelter/transitional housing) (select only one) 4 or more or total of at least 12 months in past three years 5 2-3 times in past three years 4 1 time in past three years 3 Head of household with disabling condition (physical health, mental health, substance use) that directly affects ability to secure/maintain housing 3 Criminal record for arson, drug dealing or manufacture, or felony offense against persons or property 4 Registered sex offender 5 At least one dependent child under age 6 3 Single parent with minor child(ren) 3 Household size of 5 or more requiring at least 3 bedrooms (due to age/gender mix) 3 POLICY PRIORITIES Any Veteran in household served in Iraq or Afghanistan 3
SSVF_HP_Screening_Form_FillableJanuary2019_FINAL.docx