-1- Please turn page for additional details Form H15 (1/09)

HOUSING OPPORTUNITIES FOR PERSONS WITH AIDS (HOPWA) LONG TERM RENTAL ASSISTANCE APPLICATION PACKAGE

The City of Miami HOPWA Program has a limited number of openings in its Long-Term Tenant-Based Rental Assistance (LTRA) Program and is seeking to fill these openings through a LTRA Waitlist. Applicants will be placed on the Waitlist by random lottery. If you have been diagnosed with AIDS and are low income, you may be eligible for placement on the LTRA Waitlist. WHAT IS HOPWA LTRA ASSISTANCE? The HOPWA LTRA Program provides long-term rental subsidy assistance to low income persons with an AIDS diagnosis. The goal of the LTRA Program is to assist program participants living with AIDS in achieving and maintaining housing stability so as to avoid homelessness and improve their access to, and engagement in, HIV/AIDS treatment and care. Form of Assistance Program participants must pay a portion of the rent, usually 30% of their monthly adjusted household income. The LTRA Program pays the difference. Program participants select their own market rental housing within Miami-Dade County limits (similar to the Section 8 Housing Choice Program), however, the unit must pass a housing quality standards inspection and the asking rent cannot exceed the HOPWA rent standard for Miami-Dade County (100% of the annual Miami-Dade Fair Market Rents established by the United States Department of Housing & Urban Development (HUD)). Participants’ income eligibility must be recertified annually and the rental units must pass reinspection each year. LTRA Program participants also receive the support of Housing Specialists who manage participants’ housing assistance and serve as liaisons between the participant and landlord. Housing Specialists also serve as liaison between the participant and Ryan White (or other social service) case management to ensure that the participant receives the necessary services to maintain independent living, remains engaged in health care and treatment and has access to other support services. WHO IS ELIGIBLE? You and your family are eligible IF (1) you have received an AIDS medical diagnosis, (2) you are low income (as defined by HUD), and (3) you meet the documentation requirements of citizenship or immigration status.

*Please note: The maximum income limits noted here change every year, as per HUD. You may apply as an individual or as a family. A family is a household composed of two (2) or more related persons with at least one person diagnosed with AIDS. Persons in a family may be related by ties of blood, marriage, or other legal sanctions or deemed to be important to the care or well-being of the household member with AIDS. Any individual or family who submits more than one application will be disqualified. HOW DO I APPLY? The Application Package to be submitted is made up of two forms. You must (1) fill out and sign a HOPWA LTRA 2009 Waitlist Application Form (H16 (1/09)) and (2) have your physician fill out and sign a Medical Verification of AIDS Diagnosis form (H40 (1/09)). You muust then submit both forms to the City of Miami HOPWA Program by the application deadline. WHERE CAN I FIND THE APPLICATION FORMS?

The LTRA Application Packages can be picked up at: Ryan White-funded agencies; HOPWA-funded agencies; the Miami-Dade County Main Library located at 101 West Flagler; Miami-Dade Community Action Agency (CAA) locations; City of Miami NET Offices; City of Miami Clerk’s Office, located at 3500 Pan American Drive, Miami, FL 33133; City of Miami

Household Size

1 2 3 4 5 6 7 8

Maximum Income

80% $ 33,800 $ 38,600 $ 43,450 $ 48,250 $ 52,100 $ 55,950 $ 59,850 $ 63,700

- 2 - Please turn page for additional details Form H15 (1/09)

Department of Community Development office, located at 444 SW 2nd Avenue, 2nd Floor, Miami, FL 33130. Applications can also be downloaded at The City of Miami Community Development website at http://www.miamigov.com/communitydevelopment/. APPLICATION DEADLINE Application Packages must be postmarked by April 30, 2009 to be considered for the Waitlist Lottery. MAILING AND DROP-BOX ADDRESSES Applications will only be accepted if mailed to the following address: City of Miami HOPWA Rental Assistance c/o Apple Tree Perspectives, Inc. P.O. Box 380937 Miami, Florida 33238 HOW WILL APPLICANTS BE SELECTED FOR THE WAITLIST? A random lottery process will be utilized to select applicants for placement on the HOPWA LTRA Program Waitlist. Only those Application Packages postmarked by the April 30, 2009 deadline will be placed into the lottery pool for the random drawing. The independent consulting firm of Apple Tree Perspectives, Inc. is responsible for management of the applications upon delivery. The City of Miami conducts the random lottery and produces the final LTRA HOPWA Program Waitlist. Once placed on the Waitlist, the applicant’s AIDS diagnosis and household income will be independently verified when the applicant’s waitlist number comes to the top of the Waitlist. APPLICATION INSTRUCTIONS Application Form / Medical Eligibility Verification Form Both the 2009 Waitlist Application Form and the Medical Eligibility Verification Form must be filled out completely and signed by the applicant. If either form is missing or the Medical Eligibility Form states the client does not have AIDS, your application will not be included in the random lottery process.

Medical Eligibility Form

The applicant must first fill the top portion of the Medical Eligibility form only (applicant name, date, address and social security number) and, at the bottom of the form, fill in his or her name and sign the form. The applicant’s signature authorizes the applicant’s physician to disclose the applicant’s HIV/AIDS status to the City of Miami HOPWA Program and to attest that the applicant is eligible for the program based on the applicant’s medical condition.

Then, the applicant must ask his or her physician to complete the remainder of the form and sign it.

Mail the Two Completed and Signed Forms Together The 2009 Waitlist Application Form and the Medical Eligibility Form, completed and signed where required, must be mailed together to the post office box address above by the application deadline. This is a federally-funded housing program. Any false information provided in connection with a HOPWA LTRA Program Application will be grounds for rejection of the application. Further, Title 18 Section 1001 of the United States Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any federal department or program.

City of Miami - Department of Community Development

HOPWA Long Term Rental Assistance

2009 Waitlist Application Form

Name: Date:Address:City State _________Social Security #: Phone _________________________

HOUSEHOLD INCOME: [for all household members 18 and older]

Annual Household Income (including cash assistance): $

MISCELLANEOUS: > Does anybody outside your household pay for any of your bills or give you money?

If YES, Please Explain:

> Have you ever committed any fraud in a Federally assisted housing program or been requested to repay money for knowinglymisrepresenting information of such housing programs?

If YES, Please Explain:

HOUSEHOLD COMPOSITION:

Number of Roommates: ______

Number of Family Members (including yourself): _______

IN THE FOLLOWING TABLE, PLEASE WRITE DOWN THE HOUSEHOLD COMPOSITION (INCLUDING YOURSELF)

To fill the Race Code Column on the right of the table, please use the codes listed below.

1 WHITE 4 AMERICAN INDIAN/ALASKAN NATIVE 7 ASIAN & WHITE2 BLACK/AFRICAN AMERICAN 5 NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER 8 OTHER3 ASIAN 6 BLACK/AFRICAN AMERICAN & WHITE

Gender

M / F

Relationship

to Applicant

Date of

Birth

Monthly

Income

HIV / AIDS

Status

Hispanic?

Y / N

Enter Race

Code

1

2

3

4

5

6

7

<<< Please fill out one entry

Name (As appears in

Social Security Card)Social Security #

Zip _____________

YES NO

YES NO

Applying as an Individual

Applying as a Family Unit

RECENT LIVING SITUATION

Homeless from the streets

Transitional Housing

Homeless from emergency Sheters

Psychiatric Facility

Substance abuse treatment facility

Hospital or Other medical facility

Jail/Prison

Living with relatives / friends

Domestic Violence situation

Rental Housing

Participant-Owned housing

Other (please specify____________________)

Applying with a Live-in Aide

-3-Please turn page for additional details.

Form H16 (1/09)

City of Miami - Department of Community Development

HOPWA Long Term Rental Assistance

2009 Waitlist Application Form

Name: ____________________________________ Name: ____________________________________

Address: __________________________________ Address: __________________________________

Relationship: ____________________ Relationship: ____________________

Phone: _________________________ Phone: _________________________

Name: ____________________________________

Address: __________________________________

Relationship: ____________________

Phone: _________________________ C.O.M. Only (________)

APPLICANT CERTIFICATIONS:

> I declare under penalty of perjury that:

Signature of Applicant / Head of Household Date Print Name

APPLICATION DEADLINE & SUBMISSION REQUIREMENTS:

OFFICE USE ONLY

POST MARK DATE OF APPLICATION:

APPLICATION POOL NUMBER:

PROCESSOR INITIALS:

> I understand that HOPWA Long Term Housing Assistance is contingent upon the availability of HOPWA funds.

> I have AIDS as defined by the Centers for Disease Control (CDC) and have submitted, as part of my application, my physician's independent medical verification of my HIV/AIDS status.

> I am not currently receiving any rental or utility assistance from any other local, state, or federal housing assistance program.

> I certify that the information provided to determine my eligibility for assistance on this application is true and correct to the best of my knowledge. I, the applicant, further understand that any false information provided in connection with this application may be grounds for termination from the program. I hereby acknowledge that I am applying for assistance under a U.S. HUD-funded program and that Title 18 Section 1001 of the United States Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department or agency of the United States.

I am a citizen of the United States ORI have lawful legal status to reside in the United States.

RELATIVE / FRIEND INFORMATION: I authorize the Program to contact the following individuals in case of an emergency or for receiving Program Notices & Communication in the event that the Program has difficulty locating me.

CASE MANAGER INFORMATION: If you have a case manager, please enter his/her information below.

All application packages (this form & the medical form) must be postmarked by April 30, 2009 and mailed to the following address: City of Miami HOPWA Rental Assistance, c/o Apple Tree Perspectives, Inc., P.O. Box 380937, Miami, Florida 33238.

-4-Please turn page for additional details.

Form H16 (1/09)

-5- Please turn page for additional information.

Form H40(1/09)

HOUSING OPPORTUNITIES FOR PERSONS WITH AIDS (HOPWA) CLIENT MEDICAL ELIGIBILITY FORM

CLIENT’S NAME: ______________________________ DATE: ________________________

SOCIAL SECURITY NUMBER:___________________________________________________

ADDRESS: ____________________________________________________________________

Dear Doctor: The person named above is applying for assistance through our Housing Opportunities for Persons

With AIDS (HOPWA) program. Please fill out the information on page 5 and 6, pertaining to this

client’s HIV/AIDS status and return the form to him/her.

Does this client have AIDS? Date of Initial AIDS Diagnosis ______________

Yes No (As Defined by the CDC)

Is client HIV+? Date of Most Recent HIV Test ______________

Yes No

Is the patient able to work?

Yes No

Approximately how long will the patient be unable to work? _____________

The Florida Fraud Law states that a person who knowingly aids and abets another person in obtaining aid or benefits under a state or federally funded assistance program by failing to disclose a material fact used in making a determination as to such a person’s qualifications to

receive aid or benefits, is guilty of a punishable crime. I hereby certify that the above-name individual is my patient and that he/she has tested HIV+ or has AIDS as defined by the Centers for Disease Control (CDC).

_________________________________ _______________________________

Physician’s Name (print) Signature

_________________________________ _______________________________

Clinic/Hospital/Healthcare Agency Florida License Number

Telephone: _____________________ Fax: __________________________

-6- Form H40(1/09)

AIDS without opportunistic infection

Clients CD 4 count __________ percentage ___________

AIDS with opportunistic infection Indicate below which opportunistic infections the client has had. Please initial after every

opportunistic infection designated.

Infection Candidiasis of bronchi, lungs or trachea ____________________

Candidiasis, esophageal ____________________

Cervical cancer, invasive ____________________

Coccidioidomyocis, disseminated or extrapulmonary ____________________

Cryptococcosis, extrapulmonary ____________________

Cryptosporidiosis, chronic intestinal > 1 mo. duration ____________________

Cytomegalovirus disease (other than liver, spleen, nodes) ____________________

Cytomegalovirus retinitis (w/loss of vision) ____________________

Encephalopathy, HIV-related ____________________

Herpes simplex, chronic ulcer(s) > 1 mo. duration or bronchitis, pneumonitis

or esophagitis ____________________

Histoplasmosis, disseminated or extrapulmonary ____________________

Isosporiasis, chronic intestinal ( > 1 mo. duration) ____________________

Kaposis’s sarcoma ____________________

Lymphoma, Burkitt’s (or equivalent term) ____________________

Lymphoma, immunoblastic (or equivalent term) ____________________

Lymphoma, primary, of brain ____________________

Mycobacterium avium complex or M. kansasii

disseminated or extrapulmonary ____________________

Mycobacterium tuberculosis, any site (pulmonary or extrapulmonary) ____________________

Mycobacterium, other species or unidentified species,

disseminated or extrapulmonary ____________________

Pneumonia, recurrent ____________________

Progressive multifocal leukoencephalopathy ____________________

Salmonella septicemia, recurrent ____________________

Toxoplasmosis of brain ____________________

Wasting syndrome due to HIV ____________________

Consent for Release and Exchange of Information

I, _______________________________________ hereby agree to allow City of Miami HOPWA Program to obtain (Client’s Name)

information regarding my medical condition for the purpose of qualifying me for the Housing Opportunities for Persons

with AIDS (HOPWA) Program. Such information may include HIV status, lab results, medical records and data regarding

illnesses/opportunistic infections I have had. I understand that to be eligible for HOPWA assistance there must be medical

evidence as defined by the Centers for Disease Control that I have AIDS.

____________________________________________ ____________________________ (Client’s Signature) (Date)

CD 4 – Absolute count of less than 200

OR

CD 4 percentage of less than 14