Florida Parishes Human Services Authority

(Local Lead Agency for Livingston, St. Helena, St. Tammany, Tangipahoa, and
Washington parishes)

Permanent Supportive Housing 

Immediate Housing Opportunities! 

Florida Parishes Human Services Authority (FPHSA) Permanent Supportive Housing (PSH) is
accepting application for Pine Crest Apartments in Covington, Louisiana (2, 3, & 4-bedroom
apartments); Lakeside Apartment Homes in Slidell, Louisiana (2, 3, & 4 bedroom
apartments); and Northshore Apartment Homes in Slidell, Louisiana (2, 3, & 4 bedrooms
apartments).

Applicants must have a family size of 2 to 8 members to qualify for these apartments, meet
PSH eligibility requirements as listed below, and be able to afford rent, as housing
vouchers are not available.

Applicant must be extremely low income (30% Area Medium Income Limits‐see chart 
on application); 
Applicant must have a household member with a physical, mental, or emotional 
impairment that is expected to be long‐term; and 
Applicant must be in need of supportive services. 

Stakeholders are welcomed and encouraged to assist consumers/referrals with the completion
and submission of applications.

To be considered in the selection process for the apartments listed above, completed applications
must be received no later than Friday, May 22, 2009 at the following address:

Florida Parishes Human Services Authority 

Permanent Supportive Housing
11236 Hwy 16
Amite, LA 70422 
985-748-2220-Voice
985-748-2236-Fax

Please use the attached PSH Application, as it is the most current version. Only completed
applications will be processed. A completed application is considered as having all of the
following: 
A completed PSH application form; 
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). 
 A checklist is provided on the application to ensure the applicant submits all necessary
paperwork for the processing of their application.
Livingston Parish
Judge Zoey Waguespack
Florida Parishes Tangipahoa Parish
Chris Miaoulis
Margie Mason Mark Waller, Chairman

St. Helena Parish

Human Services Authority Washington Parish
Sarah Kent Atwood J. Luter

St. Tammany Parish Executive Director

John Tobin Melanie Watkins
Marty Dean
Kathy Hayward

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) be 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 must verify 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

*Please detach this page before mailing for your records.

FLORIDA PARISHES HUMAN SERVICES AUTHORITY- ADMINISTRATIVE SERVICES
11236 HWY 16 W. • AMITE, LOUISIANA 70422
PHONE (985) 748-2220 • FAX (985) 748-2236
fphsa@dhh.la.gov
AN EQUAL OPPORTUNITY EMPLOYER
 #

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

Relationship to you

_________________________________________________________________________________
Street
_________________________________________________________________________________
City State Zip Code

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

Email:_________________________ Fax: (_____) _______–____________

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

Page 1 of 10
Your Race (Voluntary - please circle):
1. White
3. American Indian/Alaskan Native
5. Native Hawaiian/Other Pacific Islander
7. Asian and White
9. American Indian/Alaskan Native and Black
2. Black or African American
4. Asian
6. American Indian/Alaskan Native and White
8. Black/African American and White
10. Other

Your 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 for PSH to be eligible for the program. Please
check all boxes below that apply to your personal household situation.

* A member of our household has 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.

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;
Page 2 of 10
 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

PSH provides housing supports to persons with disabilities including youth, homeless persons
and elders who need these supports to be able to live in the community and not become evicted
or homeless. One example of PSH support is someone making sure you pay your rent and
utilities and keep your apartment clean. It could also be someone who makes sure you go to
medical or other appointments. On the lines below, please tell us as best you can why your
household needs these or other kinds of housing supports. If you need to, you can continue
the explanation on another piece of paper.

Check this box if you have continued to write on a separate sheet of paper.

* Our household is extremely low-income. 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
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
* includes babies and children in the household

*Please estimate the total monthly 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 slightly above the maximum, please call us about possible deductions.

YOUR CURRENT HOUSING CIRCUMSTANCES

Do you have a rental assistance voucher such as Shelter Plus Care or Section 8 voucher?
Yes No

Are you currently receiving rental assistance from FEMA? Yes No

Page 3 of 10
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 check
any boxes that describe your personal situation:

Hurricane Displacee: 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.

If you checked this box, please complete the following:

FEMA No.: _____________________________________________

FEMA Case Manager ____________________ Telephone No.: (________) ________________

What was your address at the time of Hurricane Katrina?

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?

Is this a temporary situation? Check one: Yes No

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

Homeless: Are you in one of the following situations? Check the one that applies:
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 10
 At Risk of Homelessness or Living in Transitional Housing for the Homeless: Is your
household in one of the following situations, don’t have anywhere else to live and not
enough funds to pay for housing? Check the one that applies:
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 

Inappropriately Institutionalized: 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. Check which one applies:
nursing home
ICF-DD
psychiatric facility
other residential treatment facility: _____________________________ 

At Risk of Institutionalization: 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 because (check the one that applies):
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
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 #

Page 5 of 10
*How many bedrooms does your household need? (Check box to left of appropriate bedroom size)
Efficiency apartment One bedroom
Two bedrooms Three bedrooms
Four bedrooms Five bedrooms

Is any change expected that would increase or decrease the size of your household such as a
pregnancy or a divorce? If so, please explain:

APPLICANT HOUSEHOLD’S CURRENT INCOME

Please complete the attached income chart for all members of the household and attach proof of
income.

OTHER HOUSEHOLD INFORMATION

Criminal Record: The answers to the following questions about you and your household
members 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:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_______________________________________________________________

Landlord references: List addresses for each adult household member for the last five years.

(1) Name of Primary Leaseholder:: ________________________________

Address:_____________________________ Apt # __________
City:________________________________ State:_____________
Landlord Name: _________________________________________
TelephoneNo.: ______________________
Land lord Address:_____________________________ City:_____________ State:____
Zip:_______________
Dates lived here:

Did this landlord bring any court action against the leaseholder or you?
(check one) _____ yes _____ no
Did this landlord return your security deposit?
(check one) _____ yes _____ no _____ n/a

Page 6 of 10
(2) Name of Primary Leaseholder:: ________________________________
Address:_____________________________ Apt # __________
City:________________________________ State:_____________
Landlord Name: _________________________________________
Telephone No.:______________________
Land lord Address:_____________________________ City:_____________ State:____
Zip:_______________
Dates lived here:

Did this landlord bring any court action against the leaseholder or you?
(check one) _____ yes _____ no
Did this landlord return your security deposit?
(check one) _____ yes _____ no _____ n/a

(3) Name of Primary Leaseholder:: ________________________________

Address:_____________________________ Apt # __________
City:________________________________ State:_____________
Landlord Name: _________________________________________
Telephone No.:______________________
Land lord Address:_____________________________ City:_____________ State:____
Zip:_______________
Dates lived here:

Did this landlord bring any court action against the leaseholder or you?
(check one) _____ yes _____ no
Did this landlord return your security deposit?
(check one) _____ yes _____ no _____ n/a

PSH UNITS IN FLORIDA PARISHES HUMAN SERVICES AUTHORITY REGION

Florida Parishes Human Services Authority has PSH housing in all of the locations listed below.
Check yes or no next to each parish and/or city indicating your interest in residing at that
location. Do NOT check any locations where you would not consider living.

Check if   Parish City

Interested 
     
  St. Tammany Parish Covington, LA  
St.Tammany Parish Slidell, LA
Tangipahoa Parish Amite, LA 
Tangipahoa Parish  Hammond, LA 
Washington Parish Bogalusa, LA 

Page 7 of 10
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. If so, you will be asked to sign a separate consent form allowing us to contact this person.

Name

Agency

Phone or e-mail:

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

After application is complete and signed,

attach required documentation and return all paperwork to:
Florida Parishes Human Services Authority
Permanent Supportive Housing
11236 Highway 16 West
Amite, LA 70422

Page 8 of 10
 SUMMARY OF HOUSEHOLD INCOME AND ASSET SOURCES

Please put the monthly amount of income for each household member in the boxes as appropriate

Head Member Member Member Member Member Member Member Member

Employment
#1
Employment
#2
Child
Support
Social
Security
Pension
Income
Public
Assistance
Self
Employment
SSI
SSDI
Other
Other

TOTAL

*If you receive SSI (disability), please include a copy of your award letter.
(Copies can be obtained through your local Social Security Office.)

Page 9 of 10
Employment: For each job, please list place of employment:

Other: For all other types of income listed, please explain what they are.

Documentation: Please provide documentation of all income listed such as pay stubs, copy of SSI check, etc.

ASSETS

Do you own any real estate? ___ yes ___ no

If yes, please provide the address: _______________________________________________________________

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 Member Member Member Member Member Member Member

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

Page 10 of 10
 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 Thomas Arthur, Jr. at 985‐748‐2220.  
 
Certification that you need 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: 
________________________________________________________________________________________________________________________ 
________________________________________________________________________________________________________________________ 
________________________________________________________________________________________________________________________ 
________________________________________________________________________________________________________________________ 
   
Yes  No 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. 
 
Name:            Job Title:      ___   Phone No.:       ________  
 
_________________________________________________________________________________________________________________________ 
 Agency Name                  Address         City, State           Zip 
____________________________________________________  _____________________________________ 
                                                                                  Signature                                           Date 
 Application Checklist
To ensure 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 eligibility requirements:

A member of the household has a disability;

My household is extremely low income (30% of the area’s medium income or
less); and
My household is in need of the supportive services offered by this program.

I have attached documentation of my 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.

Upon completion of the above steps, please send your application to the following address:

Florida Parishes Human Services Authority

Permanent Supportive Housing
11236 Hwy 16
Amite, LA 70401

Phone: 985-748-2220
Fax: 985-748-2236

*Please detach this page before mailing.