HUD 811 REFERRAL AGENT APPLICATION

HUD 811 REFERRAL AGENT APPLICATION
Thank you for applying to be a HUD 811 Qualified Referral Agent!

What is Section 811 Project Rental Assistance?

HUD 811 PRA is a permanent supportive housing (PSH) program offering rental assistance and supportive services for people between the ages of 18 and 61 with long-term disabilities, who may have difficulty living successfully in the community and may become homeless or institutionalized without support. Housing supports include things like reminders to pay the rent, help arranging medical appointments, and other services. Only people with disabilities who need these types of supports are eligible for HUD 811.

The Georgia HUD 811 program provides a set-aside of subsidized rental units at designated apartment buildings located around the state. Once an eligible applicant is referred to HUD 811, a confirmation email will be sent to both the Qualified Referral Agent and the Referred Participant. DCA will place the Referred Participant on a county-based housing list and will refer him/her to a property that has a vacancy in one of the requested counties when one becomes available. Position on the housing list is based on the date and time the referral was received by DCA.

What are the steps of a Qualified Referral Agent?
1. Complete the Referral Agent Application submit it with a signed Certification Form.
2. Once approved by DCA, the Referral Agent will be qualified and will have access to the Participant Referral Form.
3. The DCA HUD 811 Office will contact the newly Qualified Referral Agent to assist with training and technical assistance with the program.
4. Refer eligible applicant's to the HUD 811 to have their information reviewed and if appropriate for the program, placed on the appropriate Housing Lists.
5. Assist Referred Participants when they are referred to vacant units that become available.
6. Support HUD 811 Participants once they are housed.
Please submit the information below to become a Qualified Referral Agent.
AGENCY INFORMATION
Agency Name*
Agency Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Executive Director*

First NameLast Name
Contact Number*

Area CodePhone Number
Email*
example@example.com
HUD 811 Agency Contact*

First NameLast Name
Contact Number*

Area CodePhone Number
Email*
example@example.com
Statewide Program Affiliation (May select multiple options)*

GA Dept of Behavioral Health and Developmental DisabilitiesGA Dept of Community HealthGA Dept of Public HealthGA Dept of Human ServicesGA Dept of Community AffairsNot ApplicableOther
SUPPORT SERVICES
Which county(s) are you able to provide assistance to and send participant referrals from? (Please enter each separately by clicking the "+" sign.)*
Please list the populations you serve with a description. (Please enter each separately by clicking the "+" sign.) *
Please check the support services you can provide:*

Case ManagementInformation and ReferralHousing Tenancy SupportServices/Needs AssessmentEligibility AssessmentService Plan Development and ReviewLife Skills TrainingBasic Needs Support (ie: food, obtaining ID’s, etc.)Education ServicesAdult LiteracyGED InstructionEmployment AssistanceLegal Assistance and AdvocacyMental Health CounselingCrisis InterventionGroup/Peer CounselingOutpatient Medical Health ServicesSubstance Abuse Treatment ServicesHealth and Medical Assistance – If so, please explain:TransportationBenefits AssessmentPsychosocial AssessmentChild CareFinancial AssessmentFinancial LiteracyFinancial AssistanceHousing CounselingSecurity Deposit AssistanceUtility Assistance – If so, please explain:Moving AssistanceOther
What financial and/or in-kind support can your agency provide to assist clients/future participants with any or all of the following: 1. Help connect utilities at move in; 2. Assist with paying the security deposit; and/or 3. Assist with moving and housing set up needs.*
If you do not provide case management/tenancy support and are primarily a referral agency (ie. CoC/coordinated entry agency, advocacy group, etc.) please indicate the agencies the individuals you refer will be working with to receive case management/tenancy support.*
What contact information would you like presented on our website and sent to interested individuals as a Referral Agent? Please specify an individual, phone number, email address, and location and/or intake line familiar with the HUD 811 Program, along with any additional referral directions. If nothing is listed, the HUD 811 Contact listed above will be listed.*
Additional Information to Note*
Georgia HUD Section 811 Referral Agent Certification
Please review the following Certification Document, sign and upload it.
Please upload the signed Agency Certification of Eligibility Understanding and Authorization to Participate.*

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HUD 811 REFERRAL AGENT APPLICATION

AGENCY INFORMATION

SUPPORT SERVICES

Georgia HUD Section 811 Referral Agent Certification