Florida Parishes Human Services Authority

PUBLIC NOTICE

Louisiana Permanent Supportive Housing: Project-Based Rental Assistance

Florida Parishes Human Services Authority (FPHSA) Permanent Supportive Housing (PSH) program will be accepting
applications from March 22, 2010, through April 09, 2010, for the following housing preferences only:

Covington, Louisiana- One Bedroom Apartments

• Household size cannot exceed 2 occupants and must meet HUD occupancy standards for a one bedroom unit; and
• The Household income must be at or below twenty percent of St. Tammany Parish’s area median income.

St. Tammany Parish: 20% Area Median Income Limits

Household Size 1 Person 2 Person
Income Limit $8,380 $9,560

Bogalusa, Louisiana- Three and Four Bedroom Apartments

• Household size cannot exceed 8 members and no less than 3 members and must meet HUD occupancy standards for a
three or four bedroom unit.
• The household income must be at or below thirty percent of the area median income. (chart below)

Hammond, Louisiana- Elderly Households

• Head of household must be elderly (defined as age 62 years or older); and

• The household income must be at or below thirty percent of the area median income. (chart below)

Slidell, Louisiana- Elderly Households

• Head of household must be elderly (defined as age 62 years or older); and

• The household income must be at or below thirty percent of the area median income. (chart below)

Slidell, Louisiana- Three and Four Bedroom Apartments

• Household size cannot exceed 8 members and no less than 3 members and must meet HUD occupancy standards for a
three or four bedroom unit.
• The household income must be at or below thirty percent of the area median income. (chart below)

Household Size 1 person 2 persons 3 persons 4 persons 5 persons 6 persons

30% Area Median Income Limits
St. Tammany $12,550 $14,350 $16,150 $17,950 $19,400 $20,800
Tangipahoa $10,100 $11,500 $12,950 $14,400 $15,550 $16,700
Washington $9,050 $10,350 $11,650 $12,950 $14,000 $15,000
FY 2009 State ELI Income Limits $11,050 $12,600 $14,200 $15,800 $17,050 $18,300
Florida Parishes Human Services Authority: Public Notice (continued)

All households must meet all of the following PSH qualifications:

• The household income must be at or below the area median income as deemed above;
• The applicant must have a household member with a physical, mental, or emotional impairment that is expected
to be long-term; and
• Because of the disability, the household must be in need of supportive services in order to live independently and
successfully in the community.

A completed application is considered as having all of the following:

• A completed PSH application form;

• A completed “In-Need of PSH” verification form completed ONLY by a doctor, case manager, nurse, or other
professional; and
• Documentation of all current income.

(A checklist is provided on the application and can be utilized to assist applicants to ensure submission of all necessary
documentation.)

Stakeholders are welcomed and encouraged to assist consumers/referrals with the completion and submission of applications.
Those that need assistance to obtain and/or complete an application may contact our office at 985-748-2220. Persons with
hearing disabilities may access relay services through 711.

For your convenience, an application has been attached. Applications may also be obtained through the mail by calling 985-
748-2220. Applications will be accepted by fax or in-person through April 09, 2010, until 4:30 p.m. Applications will also
be accepted by mail and must be postmarked by the U.S. Postal Service no later than April 09, 2010. Incomplete
applications and those submitted after April 09, 2010 will not be processed. Applications must be submitted to the
address below by April 09, 2010.

Florida Parishes Human Services Authority

Permanent Supportive Housing

11236 Hwy 16

Amite, Louisiana 70422

Phone: (985) 748-2220

Fax: (985) 748-2236

 Florida Parishes
Human Services Authority
Livingston Parish St. Tammany Parish Tangipahoa Parish
Judge Zoey Waguespack John Tobin Marty Dean Chris Miaoulis
Margie Mason Kathy Hayward Mark Waller, Chairman

St. Helena Parish Executive Director Washington Parish

Sarah Kent Melanie Watkins Atwood J. Luter

Dear Applicant,

Attached is an application for the Permanent Supportive Housing (PSH) Program.

What is PSH?

PSH are special rental apartments that come with supports for people who have difficulty living successfully
in the community and may become homeless or institutionalized without supports. These housing supports
include things like reminders to pay the rent and keep your apartment clean as well as help arrange medical
appointments or other support services. Only people with disabilities including elders, youth and homeless
individuals and families who need these types of supports are eligible for PSH.

PSH Requirements

To be eligible for PSH, your household must (1) have a member who has a disability, (2) need the housing
supports offered by the PSH Program, and (3) have a household income within the HUD established income
limits, preferably extremely low-income.

How do I apply if I think I am eligible?

• First, complete the attached application. While we hope you answer all the questions, we can begin
to process your application as long as you answer all of the questions that have a asterisk next to
them. Eventually you will need to answer all of the questions and provide documents verifying your
answers. You cannot be found eligible for PSH or offered a unit until we have a complete
application and all the supporting documentation.
• Second, Florida Parishes Human Services Authority (FPHSA) must verify your household’s disability
and that you are in need of the supports offered through PSH. Please have your doctor, case
manager, or some other professional complete the attached “In-Need of PSH” Verification form and
certify it with their signature and agency information.
• Finally, send in proof of each household member’s income. Failure to comply could result in your
application not being processed.

Where do I send my completed application?

Florida Parishes Human Services Authority

Permanent Supportive Housing
11236 Highway 16 West
Amite, LA 70422

Notifications

When your application has been processed, FPHSA will notify you by mail at the address listed on your
application of your status and any needed information to determine eligibility. If you disagree with the
decision provided and would like to appeal, you may do so by adhering to the attached appeals procedure.
It is your responsibility to report any changes of address, phone number, or priority status to this office so
that we are able to locate you.

*Please detach this coversheet before mailing.

FLORIDA PARISHES HUMAN SERVICES AUTHORITY- PERMANENT SUPPORTIVE HOUSING

11236 HIGHWAY 16 WEST • AMITE, LOUISIANA 70422
PHONE (985) 748-2220 • FAX (985) 748-2236
www.fphsa.org
AN EQUAL OPPORTUNITY EMPLOYER
Serving: Livingston, St. Helena, St. Tammany, Tangipahoa, and Washington Parishes
 
 Florida Parishes
Human Services Authority
Livingston Parish St. Tammany Parish Tangipahoa Parish
Judge Zoey Waguespack John Tobin Marty Dean Chris Miaoulis
Margie Mason Kathy Hayward Mark Waller, Chairman

St. Helena Parish Executive Director Washington Parish

Sarah Kent Melanie Watkins Atwood J. Luter

APPEAL PROCESS
Applicants to the Permanent Supportive Housing (PSH) program have the right to appeal all decisions regarding their application
for the program and will be notified in writing of the following determinations, of their right to appeal these determinations, and
of the procedure for appealing determinations of:

Ineligibility based on income or need for Permanent Supportive Housing

Household size or bedroom number
Preference Status (Hurricane displace; homeless; at risk of homelessness; inappropriately institutionalized; at risk of
institutionalization)
Denial of reasonable accommodations
Removal from the waiting list

Applicants will be notified in writing of the above listed determinations and will have 10 business days from the date of the
written notice to submit a Permanent Supportive Housing Administrative Appeal Request Form seeking an administrative appeal.
Completed Administrative Appeal Request Forms can be submitted by mail, fax or in person. The Administrative Appeal
Request and any accompanying documentation will be reviewed by the PSH Program Monitor and the applicant will be notified
of the administrative appeal decision in writing within 10 business days of receipt of the Administrative Appeal Request Form.

If the applicant is not satisfied with the administrative appeal decision, he/she may request an Appeal Conference within 10
business days of the date of the written notice of the administrative appeal decision. The request for an Appeal Conference must
be made in writing and can be submitted by mail, fax, or in person. Within 3 business days of receipt of the applicant’s request,
the Florida Parishes Human Services Authority (FPHSA) Administrative Director will appoint an impartial Conference Officer.

The PSH Program Monitor will set up an appeal conference time and place notifying all parties of the location and time. Appeal
conferences may be held over the telephone or at alternate locations at the request of the applicant. The appeal conference will
be scheduled within 10 business days of the appointment of the Conference Officer, unless otherwise agreed to by the applicant,
the PSH Program Monitor, and the Conference Officer. Failure of an applicant to appear on the scheduled conference date will
result in a decision upholding the PSH Program Monitor’s position unless the applicant demonstrates good cause for not
appearing.

The appeal conference is an informal proceeding intended to determine whether the PSH Program Monitor’s determination is
reasonable in light of the information presented and in accordance with the PSH selection criteria, the Tenant Selection Manual,
and other PSH’s requirements and policies. It is the PSH Program Monitor’s burden to present information in support of its
decision, but the rules of evidence applicable in a court of law will not apply. Both the PSH Program Monitor and the applicant
are permitted, but not required, to have a representative or advocate present during the conference proceedings. An agency that
may be able to help applicants with appeals is Southeast Louisiana Legal Services, 1200 Derek Drive, Hammond, Louisiana.

Generally, Appeal Conferences shall be limited to one hour in length and each party should be prepared to present its case within
the time allotted.

The Conference Officer will determine whether the PSH Program Monitor’s determination is reasonable and in accordance with
the PSH’s selection criteria, the Tenant Selection Manual and other PSH’s requirements or policies. The Conference Officer’s
decision will be submitted in writing within 10 business days to the applicant and the PSH Program Monitor. The Conference
Officer’s determination shall be final; unless the applicant believes a local, state, or federal law has been violated in which case
the applicant has the right to pursue the matter in other venues.

If you have any questions or need further information, please feel free to call Thomas Arthur, Jr. at (985) 748-2220.

FLORIDA PARISHES HUMAN SERVICES AUTHORITY- PERMANENT SUPPORTIVE HOUSING

11236 HIGHWAY 16 WEST • AMITE, LOUISIANA 70422
PHONE (985) 748-2220 • FAX (985) 748-2236
www.fphsa.org
AN EQUAL OPPORTUNITY EMPLOYER
Serving: Livingston, St. Helena, St. Tammany, Tangipahoa, and Washington Parishes
 Florida Parishes
Human Services Authority
Livingston Parish St. Tammany Parish Tangipahoa Parish
Judge Zoey Waguespack John Tobin Marty Dean Chris Miaoulis
Margie Mason Kathy Hayward Mark Waller, Chairman

St. Helena Parish Executive Director Washington Parish

Sarah Kent Melanie Watkins Atwood J. Luter

Permanent Supportive Housing 
Administrative Appeal Request Form 
 
Date: _____________________ 
 
_________________________________________________________________________________________________________________ 
First Name                                                        MI                                                Last 
 
__________________________________________________________________________________________________________________ 
Street 
 
_________________________________________________________________________________________________________________ 
City  State  Zip Code 
 
Home: (_____) _______–____________     Work: (______) _______–____________       Mobile/Cell (_____) _______–____________  
 
________–_______–________                                  ______/______/______ 
Social Security Number                                        Birth Date 

Please describe below why you are appealing and attach all documents to support your appeal. The appeal must be 
submitted within 10 business days of the date the letter accompanying this notice. 
 
                                         
 
 
 
 
 
 
 
 
 
 

You can expect a fair decision to be made within 10 business days of your appeal form.  However, if you are not satisfied with 
the final administrative decision on your appeal, you may request an appeal conference within (10) business days from the 
date of the second notice of ineligibility. The request for a conference must be made in writing to Florida Parishes Human 
Services Authority, Louisiana Permanent Supportive Housing Program.  
 
Please Return Form To:  

Thomas Arthur, Jr. 
11236 Hwy 16 
Amite, LA 70422 
Fax (985) 748­2236 
 
FLORIDA PARISHES HUMAN SERVICES AUTHORITY- PERMANENT SUPPORTIVE HOUSING
11236 HIGHWAY 16 WEST • AMITE, LOUISIANA 70422
PHONE (985) 748-2220 • FAX (985) 748-2236
www.fphsa.org
AN EQUAL OPPORTUNITY EMPLOYER
Serving: Livingston, St. Helena, St. Tammany, Tangipahoa, and Washington Parishes 
 For LLA Use ONLY
Date Application Received: __________________________
# Time Received:
Received by:
__________________________
__________________________
Signature: __________________________
Applicant Referred by: __________________________

Permanent Supportive Housing Application

Florida Parishes Human Services Authority
Please complete the entire application as fully as possible. The application will not be considered
complete unless all of the questions that have an asterisk * are completed. Attach the required
documents and return them with the signed application to Florida Parishes Human Services
Authority at the address at the end of this application. If you have any questions, please call 985-
748-2220.

APPLICANT (Head of Household) Information Please Print Clearly

_______________________________________________________________________________
*First Name MI *Last
_________________________________________________________________________________
*Mailing Address
_________________________________________________________________________________
*City *State Zip Code

It is important that we can get in touch with you. Please provide as many phone numbers as possible.

Home: (_____) _______–____________ Work: (______)_______–____________

Email:_________________________ Fax: (_____) _______–____________

Pager: (_____) _______–____________ Mobile/Cell (_____)_______–____________

________–_______–________ ______/______/______
Social Security Number Birth Date

Optional: You may provide an alternative contact in the event that your contact information
changes and we cannot locate you.

First Name:____________________ MI: ______ Last Name:____________________

Relationship to you: __________________________

Address: _____________________________________________________________________
Street City State Zip Code

Home: (_____) _______–____________ Mobile/Cell (_____)_______–____________

Fax: (_____) _______–____________ Work: (______)_______–____________

Page 1 of 9 
Your Race (Voluntary – Please select one or more):
White Black or African American
American Indian/Alaskan Native Asian
Native Hawaiian/Other Pacific Islander American Indian/Alaskan Native and White
Asian and White Black/African American and White
American Indian/Alaskan Native and Black Other

Ethnicity (Voluntary - please select “yes” or “no” for Hispanic Origin. You should select both a
“Race” category and a “yes” or “no” for Hispanic origin): Hispanic: Yes No

Citizenship (please check) Are you a citizen of the United States? Yes No
(Some noncitizens are eligible for this program)

Gender (please check): Male Female

Veteran (please check) Yes No

Elder - Defined as a head of household over 62 years of age (please check) Yes No

Aging Out Youth: You are aging out of the state Foster Care system
(please check) Yes No

Accessibility: Does a member of your household require the special design features of a particular
unit (e.g. wheelchair access or access for person who has a hearing disability)
(please check) Yes No

If so, please give examples of accommodation(s) you need.

PERMANENT SUPPORTIVE HOUSING ELIGIBILITY

You must meet all three PSH requirements to be eligible for the program. Please check yes or
no in response to each of the three questions below. Please provide explanations as requested.

1.) *Does a member of your household have a substantial, long-term disability including
but not limited to serious mental illness, addictive disorder, developmental disability, physical or
sensory disability, chronic illness such as HIV or a frail elder?
Yes No
In order to help you access any needed supports for local or state agency it is helpful for us to
know what type of disability you have. This information is voluntary and confidential and will
NOT impact your eligibility.

Serious Mental Illness;

Addictive Disorder, i.e., individuals in treatment/recovery from substance abuse
disorder;
Developmental Disability, i.e., mental retardation, autism, or other disability
acquired before the age of 22;
(continued on the next page)
Page 2 of 9 
 Physical, sensory, or cognitive disability occurring after the age of 22;
Disability caused by chronic illness (e.g., people with HIV/AIDS who are no
longer able to work); or
Age-related disability (i.e., “frail elderly”).
Other
2.) *Do you or a member of your household need the supportive services provided by the PSH
program to allow you and/or your family to live in the community and not become evicted or
homeless?
Yes No
On the lines below, please explain why your household needs support and describe the type
of housing support needed:
Examples might include someone making sure you keep your apartment clean, pay your bills, or
go to medical or other appointments. The supports may be services you already receive or
services you would like to receive. The need for subsidized rent or financial assistance alone
does not qualify an applicant for the PSH Program.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3.) *Is your annual household income extremely low?
Yes No
The maximum annual (yearly) income a household of different sizes can have is listed below.

Household 1 person 2 persons 3 persons 4 persons 5 persons 6 persons

Size*
Maximum Income
Livingston $12,550 $14,350 $16,150 $17,950 $19,400 $20,800
St. Helena $12,550 $14,350 $16,150 $17,950 $19,400 $20,800
St. Tammany $12,550 $14,350 $16,150 $17,950 $19,400 $20,800
Tangipahoa $10,100 $11,500 $12,950 $14,400 $15,550 $16,700
Washington $9,050 $10,350 $11,650 $12,950 $14,000 $15,000
FY 2009 State
ELI Income $11,050 $12,600 $14,200 $15,800 $17,050 $18,300
Limits
* includes babies and children in the household

*Please estimate the total annual income for everyone who will live in the household: $
There is an income worksheet at the end of this application which you need to complete. If your
income is above these amounts, you may still be eligible for the program.

Page 3 of 9 
PREFERENCE POINTS

Depending upon your current housing circumstances, you may qualify for a preference under
this program. Please review the housing situations described on the next two pages and answer
all questions that might describe your personal housing situation. Failure to check off the type of
preference and the details that describe your situation will result in you not receiving those
preferences until verified.

Are you a Hurricane Displacee? Yes No

You had to move because of the 2005 hurricanes. This might be because your housing was
destroyed or because your rent was no longer affordable after the hurricane. Please note:
Displacee status for this program does not apply to those displaced by hurricanes Ike or Gustav.
If you checked this box, please complete the following:
FEMA No.: __________________________________________
FEMA Case Manager/Telephone No.: _____________________________

Please complete this section only if you are hurricanes displacee:

What was your address at the time of Hurricane Katrina?

_____________________________ __________________ ______ ______
Address City State Zip Code

Did you have to leave this address? Yes No

If you answered “yes”, were you able to return to this address? Yes No

If you answered “no”, where are you living now?

_____________________________ __________________ ______ ______
Address City State Zip Code

Is this a temporary situation? Check one: Yes No

If you answered “yes” that this is a temporary living situation, please explain:

Are you Homeless? Yes No

(If yes, check the one that applies to qualify for this preference)
Living in a car, parks, sidewalks, abandoned buildings, on the street or similar;
Living in an emergency shelter;
Living previously on the street but are now living in a transitional housing program;
Homeless but living for no more than 30 days in a hospital or other institution.

If you checked this box and are currently in a homeless shelter, please list the Shelter’s name
and telephone number:
____________________________________ (_____) ____________________
Shelter Name Telephone No.

Page 4 of 9 
Are you at Risk of Homelessness or Living in Transitional Housing for
the Homeless? Yes No
Is your household in one of the following situations, don’t have anywhere else to live and not
enough funds to pay for housing? (If yes, check the one that applies to qualify for this preference)
Household is being evicted or foreclosed within 30 days by a private landlord?
Household is being discharged within 30 days from an institution, such as a mental health
or substance abuse treatment facility, in which you lived for more than 30 days?
Household is fleeing a domestic violence housing situation?
Household is living in temporary housing situations such as in motels, hotels, and FEMA
trailers or in an untenable doubled up arrangements?
Household is exiting, mental health or developmental disability facilities, nursing homes,
residential addiction treatment programs, or hospitals?
Household includes youth aging out of foster care who qualify for PSH?
Household is living in transitional housing but did not originally come from emergency
shelter or a place not meant for human habitation 

Are you Inappropriately Institutionalized? Yes No

A household member lives in a nursing home, ICF-DD, psychiatric facility, or other residential treatment
facility, because they have a disability but would prefer to live in the community. (If yes, check the one
that applies to qualify for this preference)
nursing home
ICF-DD
psychiatric facility
other residential treatment facility: _____________________________ 

Are you at Risk of Institutionalization? Yes No

A member of the household is at risk of institutionalization if you are faced with placement in a
nursing home, Intermediate Care Facility/Developmental Disabilities (ICF/DD) or long- term
(more than 14 days) psychiatric hospital. (If yes, check the one that applies to qualify for this preference)
A caregiver is no longer able or willing to continue providing care;
A caregiver has passed away and no other caregiver is available;
You can’t stay in your temporary housing arrangement any longer;
Your household faces some other family crisis with no caregiver support available;
Someone’s health or disability status impacts the member’s ability to live independently. 

HOUSEHOLD INFORMATION
List all persons who will be living in the unit and their relationship to the Head of Household (HOH).
Complete the information in the chart for all members of the household.
First Last Name Relation to Birth Date Age Sex Social
Name Head Security #
HOH

Does a member of the household require 24-hour care by a caretaker or live-in aide? Yes No
Page 5 of 9 
SUMMARY OF HOUSEHOLD INCOME AND ASSET SOURCES
Please put the annual amount of income for each household member in the boxes as appropriate.
Head Member 2 Member 3 Member 4 Member 5 Member 6 Member7
Employment
Child Support
SSI
SSA
Pension Income
Public Assistance
Self Employment
SSDI
Other
Other
TOTAL

Employment: For each job, please list place of employment:

______________________________________________________________________________
______________________________________________________________________________
Other: Please list any other types of income:
______________________________________________________________________________
______________________________________________________________________________
Documentation: Please provide documentation of all income listed such as pay stubs, copy
of SSI checks, award letters, court ordered child support, etc.

ASSETS
1.) Do you own real estate? Yes No 
If yes, please provide the address:

____________________________ ________________ ______ __________

Address City State Zip Code
2.) Have you disposed of any assets within the last two years? Yes No
If yes, describe the asset and the amount disposed of:
________________________________________________________________________
3.) Do you have a checking and/or savings account? Yes No
If yes, list the name of the financial institution and account number:
Name of Bank: ____________________________ Account #: ____________________

Page 6 of 9 
 List below the assets of everyone to live in the unit; include all bank accounts, stocks and bonds,
trusts, real estate, etc.
DO NOT include clothing, furniture, or cars. Use additional paper if necessary.

Head Member 1 Member 2 Member 3 Member 4 Member 5 Member 6 Member 7

Checking Account
Savings Account
Stocks, Bonds
Trust
IRA, Other Pension
Other

EXPENSES

1. Do you pay for child care for a member of the household age 12 or younger that allows
you or another adult to work, look for work, or go to school?

Check one: Yes No

If so, please list the amount of child care paid and for whom:
_____________________________________________________________________________________
2. If the head, co-head, or spouse is disabled, do you have out-of-pocket medical expenses
not covered by insurance?

Check one: Yes No

If so, please list the type and amount of medical expenses:
_____________________________________________________________________________________
3. Do you have any out-of-pocket expenses (i.e. care attendant, electric wheelchair, etc.) for
a disable member of the household that allows someone to go to work?

Check one: Yes No

If so, please list the type and amount of disability expenses:
_____________________________________________________________________________________

OTHER HOUSEHOLD INFORMATION

Criminal Record: The answers to the following questions about you and your household
member’s criminal records will NOT impact eligibility for PSH. Providing us accurate and
complete information will help us make referrals of your household to landlords more successful.

Have you or any member of your household who will live in the unit have a criminal record?
Check one: Yes No

If you checked “yes”, please provide a detailed explanation of the charges and the years these
charges took place:
______________________________________________________________________________
______________________________________________________________________________

Page 7 of 9 
PSH UNITS IN FLORIDA PARISHES HUMAN SERVICES AUTHORITY REGION
Florida Parishes Human Services Authority has PSH housing throughout the region; however,
you may only apply for areas in which an open application period is announced as listed below:

Check if interested Parish Area

St. Tammany Parish Covington
St. Tammany Parish Slidell
St. Tammany Parish Slidell-Elderly Only*
Tangipahoa Parish Hammond-Elderly Only*
Washington Parish All
*Elderly is defined as age 62 or over.

COMMUNICATION
Do you have a case worker or other professional that we may contact to discuss the status of your
application (other than your local lead agency’s representative)? If so, please list their name
below. You will be asked to sign a separate consent form allowing us to contact this person.
Name
Agency
Phone or e-mail:
If you are not being referred by an agency or service provider, please provide us with the
following information:
How did you hear about the Louisiana Permanent Supportive Housing Program?
______________________________________________________________________________
______________________________________________________________________________
Where did you obtain the application? ______________________________________________
CONSENT FOR RELEASE OF INFORMATION
Your Permanent Supportive Housing application will remain confidential and will only be
discussed with you. Information will not be released without your consent.
You may give permissions to FPHSA to discuss your housing application and status with others
such as a care givers, family members, case managers, service providers, etc. To revoke this
privilege, you must provide a written statement indicating that the release of information is no
longer given to the party (ies) previously granted permission. Please list below the name and
relationship of whom you wish to have your information shared:
Name Relationship
______________________________________ ______________________________
______________________________________ ______________________________
______________________________________ ______________________________
I understand that a photocopy of this authorization is as valid as the original.
Signature:________________________________ Date:_______________

Page 8 of 9 
CERTIFICATION

Privacy Act Statement: The information on this form is being collected on behalf of the
Department of Housing and Urban Development (HUD) to help determine an applicant’s
eligibility. It will be used to provide the basis for managing the program covered by this form,
for protecting the Government’s financial interest and for verifying the accuracy of the
information furnished.

Penalty for false or fraudulent statements: U.S.C. Title 18, Sec 1001, provides that
“Whoever, in any matter within the jurisdiction of any department or agency of the United States
knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device a
material fact, or makes any false, fictitious or fraudulent statements or representations, or makes
or uses any false writing or document knowing the same to contain any false, fictitious or
fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than
five years, or both.”

Applicant(s) Statement: I/we understand that false statements or information are punishable
under federal law.

___________________________________________________________ _______________
*Applicant Signature *Date

Page 9 of 9 
 Florida Parishes Human Services Authority 
 
  “In Need of PSH”  
Verification Form 
 
This form must be completed and signed to certify that someone applying for Permanent Supportive Housing has a need 
for the tenancy supports provided in the program.  
 
Generally  a  case  manager,  services  provider,  doctor,  nurse  or  other  professional  who  knows  you  can  complete 
and  sign  the  form.  If  you  do  not  have  anyone  to  sign  the  form,  please  contact  the  Permanent  Supportive  Housing 
Department.  
 
Certification  of  the  need  for  PSH  supports  is  one  of  the  three  program  eligibility  requirements.  The  other  two  are  (1) 
having a disability, and (2) being extremely low‐income. 
 
Applicant’s Name:  ______________________  ___________________________________ 
 
Yes  No Does at least one member of this household have a physical, sensory, mental, emotional or 
cognitive disability which is expected to be chronic and/or permanent? 
 
  Explanation required: _______________________________________________________________________________________________________ 
______________________________________________________________________________________        _______________ 
______________________________________________________________________________________        _______________ 
______________________________________________________________________________________        _______________ 
 
Yes  No As a result of this member’s disability, does this household require the types of tenancy supports 
provided by the PSH Program in order to live successfully in the community and maintain a stable 
tenancy? Some of the types of supports that can be provide by the program may include assistance 
developing housing skills such as home maintenance, shopping, cooking, budgeting and bill and 
rent payment.  
 
  Explanation required: _______________________________________________________________________________________________________ 
______________________________________________________________________________________        _______________ 
______________________________________________________________________________________        _______________ 
______________________________________________________________________________________        _______________ 
   
Please  describe  how  you  believe  the  PSH  Program  supports  can  assist  the  applicant  household  to  live 
successfully in the community. Please be specific. 
 
  Explanation required: ______________________________________________________________________________________  _________ 
  ______________________________________________________________________________________        ________ 
______________________________________________________________________________________        _________________ 
______________________________________________________________________________________        _________________ 
 
I certify that the foregoing information is true and accurate to the best of my knowledge. 
 
Agency Name/ Address _______________________________________________________________________________________________________ 
              Agency        Address      City, State         Zip 
 
 

Name:             Title:        ___   Phone No.:       ________  

 
____________________________________________________     ____________________________________ 
        Signature                                                                                                            Date 
 
 
 
 
 
 
 
 
 
 

Please return this form by mail or fax: 
Florida Parishes Human Services Authority . Permanent Supportive Housing . 11236 Hwy 16 . Amite, Louisiana . 70422 . Fax: (985)748‐2236 
  
 

Application Checklist
Only completed applications will be processed. A completed application is considered as having all of
the following:

• A completed PSH application;

• Documentation of all current income (i.e. Social Security award letters, copy of
checkstubs/statements, child support court orders, etc.); AND
• A completed “In-Need of PSH” Verification form completed ONLY by a doctor, case manager,
nurse, or other professional. (Note: This form must not be completed by the applicant or
household member).

To ensure the acceptance and processing of your application, please use the following checklist before
submitting your application:

My application is complete and contains my most accurate and current information.

I meet all three eligibility requirements:

A member of my household has a disability;

My household is extremely low income; and
Because of the disability, my household is in need of the supportive services offered by
this program.

I have attached documentation of my household’s current income (i.e. award letters, check
stubs, etc.)

I have attached the “In-Need of Supportive Services” form that was completed and certified
ONLY by a case manager, services provider, doctor, nurse or other professional.

Once completed, you may send your application to the following address:

Florida Parishes Human Services Authority

Permanent Supportive Housing
11236 Hwy 16
Amite, LA 70422

Fax: 985-748-2236

*Please detach this page before mailing.