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045-20 - Kitsap Community Resources - ContractContract No. 045-20 AFFORDABLE HOUSING SERVICES AGREEMENT This Affordable Housing Services Agreement ("Agreement") is entered into by and between Kitsap Community Resources, a Washington non-profit social services agency (hereinafter "KCR"), and the City of Port Orchard, a Washington State municipal corporation (hereinafter the "City" and collectively the "Parties"). I. RECITALS A. KCR is a non-profit social services agency organized and existing under the laws of the State of Washington; and B. The City of Port Orchard is a Washington municipal corporation organized and existing under the Washington State Constitution and the laws of the State of Washington, and particularly those set forth at RCW Title 35A; and C. In the 2019 legislative session, the Washington state legislature passed SHB 1406 (codified at RCW 82.14.540), which created a sales tax revenue sharing program that allows the City to access a portion of state sales tax revenue (hereinafter, the "Funds") to make local investments in affordable housing over a 20-year term; and D. The City has taken the necessary steps to take advantage of this funding source to assist the citizens of Port Orchard by investing in housing assistance programs serving those below the 60% median income level; and E. After reviewing applications from entities capable of providing affordable housing assistance to the residents of Port Orchard, KCR was selected to utilize the Funds to effectively provide housing assistance for low-income residents of the City through its existing Housing Solutions Center, and KCR has demonstrated capability to operate such a program effectively; and F. The City desires to engage the services of KCR to perform the public services described herein and undertake the proposed program; NOW, THEREFORE, in consideration of the foregoing, and in consideration of the premises, terms and conditions set forth below, it is hereby agreed as follows: II. AGREEMENT 1. Affordable Housing Services. The City desires to engage KCR—through its existing Housing Solutions Center —to administer an affordable housing program for the City, AFFORDABLE HOUSING SERVICES AGREEMENT Page 1 of 8 utilizing the Funds allocated to the City pursuant to SHB 1406 to assist citizens of Port Orchard with rental assistance (the "Program"). A. KCR's Duties. KCR shall administer the Program, and in administering the Program, KCR shall comply with all applicable state and local laws, and shall exclusively utilize the Funds to provide rental assistance (or rental and utilities assistance if utilities are included in the rent payment), to those Port Orchard residents with an 0-60% of the Area Median Income (AMI). Such rental assistance may only be provided for housing located within the City of Port Orchard, and the maximum per -household cap for assistance under the Program is Two Thousand Dollars ($2,000.00). KCR shall confirm with the City the amount of funds available prior to awarding funds to an applicant. Additional parameters for the Program are attached hereto as Exhibit A and incorporated herein by this reference. B. City's Duties. On a monthly basis, the City may provide to KCR the Funds the City receives. The City shall have no additional payment obligations to KCR, and if the City receives no Funds in a particular month, KCR shall receive no Funds. Payment by the City of the Funds under this Agreement shall occur as follows: i. Upon identifying a qualified applicant for rental assistance, KCR shall contact the City to request a statement identifying the available Funds. Contact may occur via e-mail or phone to the City's Finance Director (or designee), and the statement may be provided via e-mail or letter. ii. Upon receipt of the City's statement of available Funds, KCR shall issue an invoice to the City, which may be transmitted via e-mail or mail. The invoice shall not exceed the amount of available Funds. iii. Upon receipt of an invoice, the City shall issue payment for the invoiced amount, provided the invoiced amount shall not exceed the amount of available Funds. The City shall have no obligation whatsoever to pay to KCR an amount exceeding the available Funds. iv. Of the Funds provided to KCR, KCR will be entitled to retain Eight and Eight Tenths Percent (8.8%) of the Funds provided by the City to pay for the administrative services associated with the Program. 2. Duration. This Agreement will commence upon mutual execution of this Agreement, and will expire on December 31, 2020 unless terminated prior to the expiration date by one of the Parties pursuant to this Agreement; provided, the parties may extend the Agreement for one additional year term by execution of an addendum to this Agreement. AFFORDABLE HOUSING SERVICES AGREEMENT Page 2 of 8 3. Termination. Either party may terminate this Agreement with or without cause upon thirty (30) days' advance written notice to the other party. In the event of termination, KCR will perform such additional work as is necessary for the orderly closing out of the Program, and will be entitled to use any remaining Funds transmitted by the City for the month in which the termination is effective to provide affordable housing assistance and reimbursement of the actual costs associated with closing out the Program. Upon expiration of the Agreement, all unused Funds shall be returned to the City. 4. Insurance. A. The Consultant shall procure and maintain for the duration of the Agreement, insurance against claims for injuries to persons or damage to property which may arise from or in connection with the performance of the work hereunder by the Consultant, its agents, representatives, or employees. B. No Limitation. Consultant's maintenance of insurance as required by the agreement shall not be construed to limit the liability of the Consultant to the coverage provided by such insurance, or otherwise limit the City's recourse to any remedy available at law or in equity. C. Minimum Scope of Insurance. Consultant shall obtain insurance of the types described below: 1. Automobile Liability insurance covering all owned, non -owned, hired and leased vehicles. Coverage shall be written on Insurance Services Office (ISO) form CA 00 01, or a substitute form providing equivalent liability coverage. If necessary, the policy shall be endorsed to provide contractual liability coverage. 2. Commercial General Liability insurance shall be written on ISO occurrence form CG 00 01, or a substitute form providing equivalent liability coverage and shall cover liability arising from premises, operations, independent contractors and personal injury and advertising injury. The City shall be named by endorsement as an additional insured under the Consultant's Commercial General Liability insurance policy with respect to the work performed for the City. 3. Workers' Compensation coverage as required by the Industrial Insurance laws of the State of Washington. 4. Professional Liability insurance appropriate to the Consultant's profession. AFFORDABLE HOUSING SERVICES AGREEMENT Page 3 of 8 D. Minimum Amounts of Insurance. Consultant shall maintain the following insurance limits: 1. Automobile Liability insurance with a minimum combined single limit for bodily injury and property damage of $1,000,000 per accident. 2. Commercial General Liability insurance shall be written with limits no less than $1,000,000 each occurrence, $2,000,000 general aggregate. 3. Employer's Liability each accident $1,000,000, Employer's Liability Disease each employee $1,000,000, and Employer's Liability Disease — Policy Limit $1,000,000. 4. Professional Liability insurance shall be written with limits no less than $1,000,000 per claim and $1,000,000 policy aggregate limit. E. Other Insurance Provisions. The insurance policies are to contain, or be endorsed to contain, the following provisions for Automobile Liability, Professional Liability and Commercial General Liability insurance: 1. The Consultant's insurance coverage shall be primary insurance as respect the City. Any insurance, self-insurance, or insurance pool coverage maintained by the City shall be excess of the Consultant's insurance and shall not contribute with it. 2. The City will not waive its right to subrogation against the Consultant. The Consultant's insurance shall be endorsed acknowledging that the City will not waive their right to subrogation. The Consultant's insurance shall be endorse to waive the right of subrogation against the City, or any self- insurance, or insurance pool coverage maintained by the City. 3. The Consultant's insurance shall be endorsed to state that coverage shall not be cancelled by either party, except after thirty (30) days prior written notice by certified mail, return receipt requested, has been given to the City. If the General Liability coverage is written on a "claims made" basis, then a minimum of a three (3) year extended reporting period shall be included with the claims made policy, and proof of this extended reporting period provided to the City. 4. If the Professional Liability Coverage is written on a occurrence form. If the Professional Liability coverage is only available on a "claims made" basis, then then a minimum of a three (3) year extended reporting period shall be included with the claims made policy, and proof of this extended reporting AFFORDABLE HOUSING SERVICES AGREEMENT Page 4 of 8 period provided to the City. If the Consultant is not able to purchase the three (3) year extended reporting period endorsement then as an option the Consultant shall agree that if the Consultant's firm is dissolved or merged, then the Consultant shall purchase before the dissolution or merger of the Consultant's company, the three (3) year extended reporting period coverage for the Professional Liability coverage. F. Acceptability of Insurers. Insurance is to be placed with insurers with a current A.M. Best rating of not less than A:VII. G. Verification of Coverage. Consultant shall furnish the City with original certificates and a copy of the amendatory endorsements, including but not necessarily limited to the additional insured endorsement, evidencing the insurance requirements of the Consultant before commencement of the work. 5. Indemnification A. Indemnification — City. The City does hereby agree to save harmless and defend KCR from all claims and liability due to the negligent acts, errors, or omissions of the City, its agents and/or employees, except for claims caused by the sole negligence of KCR. Such indemnity will include, but not be limited to all out-of- pocket expenses incurred by KCR, including attorney's fees, in the event the City fails or refuses to accept the tender of any claims brought against KCR, the basis for which are negligent acts, errors or omissions of the City, its agents and/or employees. B. Indemnification — KCR. KCR does hereby agree to save harmless and defend the City from all claims and liability due to the negligent acts, errors or omissions of KCR, its agents and/or employees, except for claims caused by the sole negligence of the City. Such indemnity will include, but not be limited to, all out- of-pocket expenses incurred by the City, including attorney's fees, in the event KCR fails or refuses to accept the tender of any claims brought against the City, the basis for which are negligent acts, errors or omissions of KCR, its agents and/or employees. C. Should a court of competent jurisdiction determine that this Agreement is subject to RCW 4.24.115, then, in the event of liability for damages arising out of bodily injury to persons or damages to property caused by or resulting from the concurrent negligence of KCR and the City, its officers, officials, employees, and volunteers, KCR's liability, including the duty and cost to defend, hereunder shall be only to the extent of the KCR's negligence. AFFORDABLE HOUSING SERVICES AGREEMENT Page 5 of 8 D. The foregoing indemnity is specifically and expressly intended to constitute a waiver of each party's immunity under Washington's Industrial Insurance Act, RCW Title 51, as respects the other party only, and only to the extent necessary to provide the indemnified party with a full and complete indemnity of claims made by the indemnitor's employees. The parties acknowledge that these provisions were specifically negotiated and agreed upon by them. 6. Entire Agreement / Amendments. This Agreement, together with any attachments or addenda, represents the entire and integrated Agreement between the Parties hereto, and supersedes all prior negotiations, representations, or agreements, either written or oral. It is mutually agreed and understood that no amendment of any of the terms of this Agreement will be valid unless made by written instrument properly signed by both Parties. 7. Notices. Except as otherwise identified in this Agreement, any notices required to be given by the City to KCR, or by KCR to the City, will be in writing and delivered to the Parties at the following addresses: KCR City of Port Orchard John Koch, Director Robert Putaansuu, Mayor Housing & Community Support Services 216 Prospect Street 1201 Park Avenue Port Orchard, WA 98366 Bremerton, WA 98337 8. Compliance with Laws. KCR and the City will comply with all federal, state and local laws, rules, regulations and ordinances applicable to the performance of this Agreement, including without limitation all those pertaining to wages and hours, confidentiality, disabilities and discrimination, including but not limited to the Americans with Disabilities Act and all regulations interpreting or enforcing such Act. 9. Maintenance and Audit of Records. KCR will maintain books, records, documents and other materials relevant to its performance under this Agreement, which sufficiently and accurately reflect any and all direct and indirect costs and expenses incurred or paid in the course of performing this Agreement. These records will be subject to inspection, review and audit by the City, the Washington State Auditor's Office, and authorized federal agencies. Both Parties will retain all such books, records, documents and other materials as required by the Washington State Records Retention policy as established by the Secretary of State. In the event the City receives a public records request for records pertaining to this Agreement and/or the Program, KCR agrees to assist the City to meet the City's obligations under the Public Records Act, Ch. 42.56 RCW, at KCR's sole cost. 10. Reporting. KCR will submit to the City on a quarterly basis a detailed accounting of the costs of Program operations. KCR will assist the City by providing any information needed AFFORDABLE HOUSING SERVICES AGREEMENT Page 6 of 8 for the City to compile and submit the reports required to by the State of Washington under RCW 82.14.540(11). 11. Waiver Limited. A waiver of any term or condition of this Agreement must be in writing and signed by the waiving Party. Any express or implied waiver of a term or condition of this Agreement will apply only to the specific act, occurrence or omission and will not constitute a waiver as to any other term or condition or future act, occurrence or omission. 12. Default / Dispute Resolution. If either KCR or the City fails to perform any act or obligation required to be performed by it hereunder, the other party will deliver written notice of such failure to the non -performing party. The non -performing party will have thirty (30) days after its receipt of such notice in which to correct its failure to perform the act or obligation at issue, after which time it will be in default ("Default") under this Agreement; provided, however, that if the non-performance is of a type that could not reasonably be cured within said thirty (30) day period, then the non -performing party will not be in Default if it commences cure within said thirty (30) day period and thereafter diligently pursues cure to completion. In the event a default continues and/or any dispute arises (for anything other than non- payment) between the Parties, either party may request in writing that the issue be resolved by mediation. If the parties are unable to resolve the dispute within ninety (90) days, then either party will have the right to exercise any or all rights and remedies available to it in law or equity. In any suit or action instituted to enforce any right granted in this Agreement, the substantially prevailing party shall be entitled to recover its costs, disbursements, and reasonable attorneys' fees from the other party. 13. Venue and Choice of Law. Any action at law, suit in equity, or other judicial proceedings for the enforcement of this Agreement or any provision thereof will be instituted only in the courts of the State of Washington, Kitsap County. It is mutually understood and agreed that this Agreement shall be governed exclusively by the laws of the State of Washington, both as to interpretation and performance. 14. Assignment and Subcontracting_. KCR may not assign, transfer, delegate, subcontract or encumber any rights, duties, or interests accruing from this Agreement without the express prior written consent of the City, which consent may be withheld at the sole discretion of the City. 15. Severability. If any term or provision of this Agreement should be held to be invalid or unconstitutional by a court of competent jurisdiction, such invalidity or unconstitutionality will not affect the validity or constitutionality of any other term or provision of this Agreement, and this Agreement will be construed in all respects as if such invalid or otherwise unenforceable term or provision was omitted. AFFORDABLE HOUSING SERVICES AGREEMENT Page 7 of 8 16. Independent Contractor. KCR is and will be at all tunes during the term of this Agreement an independent contractor. Nothing in this Agreement will create an employee/employer relationship between the Parties. 17. independent Parties. The Parties to this Agreement, in the performance of it, will be acting in their individual capacities and not as agents, employees, partners, joint ventures, or associates of one another. The employees or agents of one party will not be considered or construed to he the employees or agents of the other party for any purpose whatsoever. 18. Counte arts. This Agreement may be executed by the Parties using duplicate counterparts. FOR KITSAP COMMUNITY RESOURCES Vlq ,clay of .2010 Jeff le , xecutive Director FOR THE CITY OF PORT ORCHARD Adopted this'-�19 day of f f , 20 7-6 Robert Putaansuu, Mayor ATTEST/AUT CATED: Brandy Rtnearson; I4MC, City Clerk APP FD AS TO Charlotte A. Archer, City Attorney AFFORDABLE HOUSING SERVICES AGREEMENT Page 8 of 8 EXHIBIT A Statement of Work The contract award will provide funds for the administration of the City of Port Orchards Affordable Housing Program utilizing the Funds allocated to the City pursuant to SHB 1406 to assist citizens of Port Orchard with rental assistance based on the following criteria: • Must be a resident of the City of Port Orchard, WA • Housing must be within the city limits of Port Orchard, WA • Must be a Senior over the age of 62 or a Military Veteran ■ Income Verification (Household must be under 60% AMI • Must have pay or vacate notice or homeless verification ■ Must provide lease or sample lease if moving in • Use the HUD definition of homelessness (Living ion street, shelter, car, place not meant for habitation, or fleeing DV Funds awarded can be used for the following: • Rent or rent/utilities if utilities are included with rent • Limited to no more than $2,000.00 per household Kitsap Community Resources will maintain data in the HMIS system on this program and provide quarterly reports to the City on the use of the funds and number of households served. Ausing Solutions Center of Kitsap County Full Name: Current Address (or Last Permanent Address if homeless] Street Address: Phone #1: Phone #2: (HOME/CELL/MESSAGE) City: Today's Date: (HOME/CELL/MESSAGE) List ALL household members below, starting with yourself as Head of Household. State: Email: Zip Code: ❑ NC Full Name (First, Middle, Last) Age Date of Birth Social Security # ,�, (' Race (W = White, B = Black, A = Asian, N = Native American, P = Pacific Islander) ?� 11 u $A = `O ? ?I a Relationship To You SELF Where did you stay last night? (Check ONE only) ❑ Non -housing (car, street, tent, etc.) ❑ Emergency Shelter ❑ Staying with Family ❑ Staying with Friends ❑ Rental (apartment, house, etc.) ❑ Home you Own ❑ Hotel or Motel ❑ Hospital ❑ Psychiatric Facility ❑ Substance Abuse Facility ❑ Jail or Prison ❑ Transitional Housing ❑ Other (please specify); How long have you stayed there? If less than 90 days, where did you stay the night before? Monthly Rent Amount: $ Were you referred to HSC by a school district; school counselor; and/or learning specialist? ❑ Yes ❑ No Did you receive a pay or vacate notice? ❑ Yes ❑ No If YES, how much do you owe? $ Are you living on the streets, in an emergency shelter, or safe haven? ❑ Yes ❑ No ❑ Don't Know If YES, what is the approximate date you started living on the streets, in shelter, or safe haven?_/� How many times have you lived on the streets, in shelter or safe haven in the past three (3) years? How many total months have you lived on the streets, in shelter or safe haven in the past three (3) years? 4,41 1_ using Solutions Center of Kitsap County Does your household have any of the following disabilities or barriers to housing? (Please answer ALL) Physical Disability ❑ Yes ❑ No ❑ Don't Know If yes, which household member(s)? Developmental Disability ❑ Yes ❑ No ❑ Don't Know If yes, which household member(s)? Chronic Health Condition ❑ Yes ❑ No ❑ Don't Know If yes, which household member(s)? Mental Health Issue ❑ Yes ❑ No ❑ Don't Know If yes, which household member(s)? Substance Use Issue ❑ Yes ❑ No ❑ Don't Know If yes, which household member(s)? Long-term physical disability? ❑ Yes ❑ No Does it limit your independence? ❑ Yes ❑ No Long-term Chronic Health Condition? ❑ Yes ❑ No Long-term mental health issue? ❑ Yes ❑ No Please check one ❑ Drug ❑ Alcohol ❑ Both Long-term Substance Use Issue? ❑ Yes ❑ No Have you been a victim of domestic or intimate partner violence? ❑ Yes ❑ No If YES, how long ago? Are you currently fleeing domestic violence? ❑ Yes ❑ No ❑ Don't Know List ALL household income below. Please list each a rson with income, each source of income, and the monthly $ amount. Examples: Employment, SSI, SSDi, Retirement, TANF, Unemployment, Child Support, etc. Household Total: 1 using Solutions Center of Kitsap COUnty What Non -Cash Benefits are your household currently receiving? (Check ALL that apply) ❑ NONE ❑ SNAP (FOOD STAMPS) ❑ WIC ❑ TANF Childcare ❑ TANF Transportation ❑ Other TANF Funded Services ❑ Section 8 ❑ Temporary Rental Assistance ❑ Other (please specify): Check each Health Insurance type your household is receiving, and write the name(s) of who receives it. Please account for ALL household members, even those without health insurance. If "Other", write the type of insurance in the parentheses. ❑ NOT COVERED: ❑ MEDICAID/Apple. ❑ MEDICARE: ❑ SCHIP: ❑ VA Medical: ❑ Employer Provided. - El COBRA: ❑ Private Insurance: ❑ State Health Insurance for Adults: ❑ Other If your last permanent residence was OUTSIDE Kitsap County, what is the main reason you came to Kitsap? (Check ONE only) ❑ Returning to the Area ❑ To Help Family/Friends ❑ To Get Help From Family/Friends ❑ Better Cost of Living ❑ Employment Opportunities ❑ Education Opportunities ❑ Military Connection ❑ Offer of Public Housing ❑ Seeking Medical/Recovery Treatment ❑ To Access Social Services ❑ Found Kitsap on Internet ❑ Fleeing Domestic Violence ❑ Assigned by D.O.C. ❑ Other (specify): Were you contacted by an Outreach Specialist outside of this office? Yes / No If Yes, Where? ❑ Ferry Terminal ❑ Library ❑ Jail ❑ Drug Court ❑ KRC ❑ Olympic College ❑ Community Event ❑ Other Do you have any pets? ❑ Yes ❑ No If so, how many? And what kind(s)? Is anyone in your household pregnant? ❑ Yes ❑ No If YES, when is the due date? Is anyone in your household a veteran, or the child or spouse of a veteran? ❑ Yes ❑ No Have you or any member of your household ever been convicted of a criminal offense? ❑ Yes ❑ No ❑ Don't Know If you checked "Yes", please explain: an i using Solutions Center of Kitsap County (REQUIRED): In your own words, what brought you into the Housing Solutions Center today? I certify that I have provided the above information, which is accurate and true. I understand that I may be subject to criminal prosecution if I have knowingly provided false information. I also give my permission for this agency to request/release necessary information that may result in my receiving benefits and for reporting purposes. I understand that provision of my Social Security Number is necessary to avoid duplicate assistance benefit payments to the same applicant household and may also be used for income verification. I hereby authorize Housing Solutions Center of Kitsap County staff to use my Social Security Number for those purposes only. I understand that Housing Solutions Center of Kitsap County may request a Washington State background investigation before considering my application. By signing, I grant permission for that investigation. Applicant Signature Date HSC Representative Signature Da Kitsap Client Release of Information and Informed Consent form Washington State Homeless Management information System (HMIS) Kitsap HMIS Collaborative Agencies This agency participates in the Washington State Homeless Management Information System (HMIS) by collecting information, overtime, about the characteristics and service needs of people facing homelessness. RCW 43.185C.180 and RCW 43.185C.030 ■ To provide the most effective services in moving people from homelessness to permanent housing, we need an accurate count of all people experiencing homelessness in Washington State. In order to insure that clients are not counted twice, we need to collect four pieces of personal information. Specifically, we need: name, birth date, race/ethnicity. You may also choose to provide your social security number. However, signing this form does not require you to do so. Your information will be stored in our database for 7 years after the last date of service, If you have questions about collection of data or your rights regarding your personally identifying information, contact the HMIS System Administrator at: (360) 725-3028 ■ We use strict security policies designed to protect your privacy. Our computer system is highly secure and uses up-to-date protection features such as data encryption, passwords, and two -factor authentication required for each system user, There is a small risk of a security breach, and someone might obtain and use your information inappropriately. If you ever suspect the data in HMIS has been misused, immediately contact the HMIS System Administrator at: (360) 725-3028 ■ The data you provide may be combined with data from the Washington State Department of Social and Health Services (DSHS) and Education Research and Data Center for the purpose of further analysis. Your name n identifying Informati n will not be included In any reoRrts or publications, Only a limited number of staff members, who have signed confidentiality agreements, will be able to see this information. Your information will not be used to determine eligibility for DSHS programs. Washington State HMIS system administrators have full access to all information in HMIS. This includes the Department of Commerce staff, designated HMIS system administrators, and the software vendor. By signing this form, you acknowledge and allow Department of Commerce staff to obtain additional records of information from other state agencies with which there is a data sharing agreement (DSA) on file between Commerce and the other agency. Our DSA guides data transfer and storage security protocols. If DSAs are In place, Commerce is authorized by you to obtain, add to HMIS, and use for evaluation purposes any other data you have provided to other Washington state agencies. • Your decision to participate in the HMIS will not affect the uuality,or,puantity of services ,you aare„elligibieto receive from this agency, and will not be used to deny outreach, assistance, shelter or housing. However, If you do choose to participate, services In the region may improve if we have accurate information about homeless individuals and the services they need. Furthermore, some funders MAY require that you consent to provide your personally Identifying information in HMIS in order for you to receive services from that funding source. I understand the above statements and consent to the Inclusion of personally identifying information in HMIs about me and any dependents listed below, and authorize information collected to be shared with partner agencies, both state agencies and organizations that participate In the Kitsap HMIS Collaborative. I understand that my personally Identifying information will not be made public and will only be used with strict confidentiality. I also understand that I may withdraw my consent at any time by filing a 'Client Revocation of Consent' form with this agency. I understand that 1 may obtain a copy of my signed consent form from this Agency (including forms signed electronically). IMPORTANT: Do not enter personally identifying information Into HMIS for clients who are: 1) in pV agencies or; 2) currently fleeing or In danger from a domestic violence, dating violence, sexual assault or stalking situation; 3) are being served In a program that requires disclosure of HIV/AIDS status (i.e.; HOPWA); or 4) under 13 with no parent or guardian available to consent to enter the minor's information in HMIS. If this applies to you, STOP— and dip nol slan this form. Dependent(s) First & Last Name(s): Client Name: Signature: Staff Name: - Signature: Date of Birth: Date: Agency: HMIS # © NC Revised 612014 . �_ using Soy utions Center of Kitsap County CONSENT TO SHARE INFORMATION WITH PARTNERSHIP AGENCIES PLEASE READ THE FOLLOWING CAREFULLY The HOUSING SOLUTIONS CENTER (HSC), administered by KITSAP COMMUNITY RESOURCES (KCR), is requesting your permission to share your confidential information and records in order to provide you writh outreach services that are provided by other programs and agency. You are not required to give your consent to share this confidential and personal information. If you do agree to share your confidential information and personal records, this information will be shared with partnering agencies in the community and only on a need -to -know basis. The sole purpose of revealing this information will be to enable the HSC staff, under the administration of Kitsap Community Resources, to provide you with appropriate external and internal services. If you do not consent to share your confidential information and records, those records will only be shared to the extent allowed by state and federal law. Your eligibility to participate in HSC programs does not depend on your agreement to share your confidential information and personal records with outside agencies. If you choose not to share your confidential information and personal records, including your Social Security Number, you may not be eligible for further services that require inter -agency cooperation, The information disclosed to the HSC partnering agencies will not be further re -disclosed by those agencies without your specific authorization and further consent. I agree that a photocopy of this authorization may be used for the purpose stated above. Signature Date ���� me cox�uui�in Ctlf�YJ "using Solutions Center of K itsa p County Homeless Grant Funding Application Head of Household ONLY: First Name: Last Name: - ..Date Anfamily member over the are of 60? Any family member under the age of 5? Any family member pregnant? In the last year have you: YES NO Been released from an inpatient chemical dependency program'-, What Facility? When? Been released from an inpatient mental health facility? What Facility? When? Used crisis service, including crisis centers or suicide prevention hotlines? Are you currently? YES NO Are you currently enrolled in an outpatient chemical dependency program" What facility? Areyou currently receiving treatment for a serious mental illness? Drinking or using drugs after completing a treatment 2rogram? Experiencing violence or fear for your safety in your household? Effected b° a developmental or learriindisability? Receiving treatment for a chronic medical condition? If Yes. what is the condition? Having experienced any emotional, physical, psychological, sexual or other type of abuse or trauma which You have not Sought help for, and/or which has caused homelessness? Have a permanent physical disability that limits mobility? Have you: YES I NO Been convicted of a felony in the past 3 years' Ever been homeless for a vear or more or been homeless for 3 or more times? If you do not receive assistance today and are homeless, where will you sleep tonight? Select one, if you know: Emer�encX shelter In a vehicle Site without water or electricity With someone who is abusing me or another member of my family Monthly Household Income