Referral Form. Current address. How long has the participant been residing at this location?

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1 Referral Form The Graduated Rent Subsidy (GRS) Program provides an opportunity for individuals and/or families who have successfully graduated from a Housing First Program and no longer require case management, but do require a subsidy to maintain stable housing within the community. Our mandate is to provide individuals or families, whose main barrier to achieving long term housing stability is finances, financial assistance to minimize recidivism of shelter use as part of Calgary s 10 year plan to end homelessness. To participate in this program, applicants must have achieved 6 months of stable housing at current address with a demonstrated ability to pay their portion of rent and provide a landlord & case manager reference. Please ensure the attached release of information have been completed and faxed along with this form to ATTN: GRS Please complete this form as fully as possible. Referring agencies will be contacted and an appointment will be scheduled for Case Manager and participant to attend Participant s name DOB Gender Referring Agency Referred by Date Referred Phone number Current address How long has the participant been residing at this location? Telephone number(s) where applicant can be reached (please indicate if the number is cell, home, office, friend, etc.) Does the participant identify as Aboriginal? Yes No Immigration Status? Is the applicant pregnant? Yes No If yes, please indicate due date Connected to CUPS Doctor? Yes No If yes, indicate Dr. name 1. Does the applicant have a source of stable income? Yes No If yes, please provide brief details of source & amount(s)

2 2. Does the applicant owe any outstanding debt(s) Ie. Calgary Housing, Landlord, Utilities? Yes No If yes, please provide brief details 3. Does the applicant mutually agree with the case manager that they re stable in their housing and does not require any case management? Yes No If yes, please provide brief details 4. Has the applicant moved in the past 6 months? Yes No If yes, please provide brief details, 5. Current application on file at Calgary Housing? Yes No 6. Current Bank account? Yes No 7. Current tax assessment? Yes No Provide Line Acuity Assessment over time, please provide 9. Able to provide photo ID? Yes No 10. Landlord available for follow-up reference? Yes No Please provide phone # 11. Has the applicant completed money management or financial planning course Yes No If yes, please provide brief details 12. Crisis plan provided by case management in case of housing instability? Yes No

3 GRS OFFICE USE ONLY Has an intake been scheduled for the applicant? Yes No Note(s): The applicant has been ACCEPTED into the program for the following reasons: The applicant has been DECLINED involvement with the program for the following reasons and referred to (List the 3 Agencies): GRSP Signature Date

4 Release of Information Your signature in the space below allows the Graduate Rent Subsidy Program staff to receive and/or release information on your behalf with the following agencies for the purpose of accessing applicant suitability into the program. Referring Agency CUPS Staff Landlord/Property Managers Calgary Housing Company This consent will be effective until Date (mm/dd/yyyy) not to exceed one year I understand that this consent can be cancelled or changed at any time and that any change must be in writing. Print Name Signature / Date (mm/dd/yyyy) Agency Representative / Date (mm/dd/yyyy)

5 What GRS offers: Financial assistance in order to maintain stable housing in the community Financial support is reassessed every 3 months Applicant Responsibilities: Pay agreed upon rent and related household expenses on time each month Be a respectful tenant and neighbor Notify us 30 days prior to moving in writing chriss@cupscalgary.com Notify us of income changes with 1 month of changes Notify us if the number of people in your household changes Referring Agency Responsibilities: Case management agencies may have to re-instate the participant back into their case management program, within the initial 12 month period of subsidy acceptance. A participant would become reinvolved in case management under the following circumstances: Rental arrears (portion expected from participant) Eviction Notice provided Behavioural problems - Eviction Notice provided Please note under these circumstances, the participant no longer fits the mandate of the GRSP and subsidy will stop. The referring agency will be notified and a decision will be made by the case management agency as to if the participant will return to case management for a minimum 6 month period before re-applying or the eviction will stand. Short term interventions may be needed, where the participant will continue to receive GRS. These interventions should require less than 30 days from first report. They include: Tenancy issues where no eviction has been issued Safety Related Issues Deterioration of Health (Mental, Physical, or Relapse in addiction) Decrease in finances In the event that the intervention requires more than 30 days to address individuals will be reinstated back into the case management program and staff of the GRSP will be informed that the participant will no longer receive the graduate rent subsidy. Communication Timelines Follow up will occur with the referring agency within 5 working days of receiving the referral, to acknowledge receipt of the referral, indicate if the referral meets eligibility criteria, as well as indicate an estimated wait time for acceptance into the program