Household Services and Outcomes Report, 52698

U.S. Department of Housing and Urban Development OMB Approval Number 2528-0331

Office of Policy Development and Research Expires xx-xx-xxxx

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless that collection displays a valid OMB control number.

Eviction Protection Grant Program

Client Services and Outcomes Report

A. Client Served

1. Client

1a. Client Unique ID _____________________________

1b. Limited English Proficiency? ☐ Yes ☐ No

1c. Gender Identity (select all that apply)

☐ Female ☐ Male ☐ Transgender ☐ Non-binary/non-conforming ☐ Prefer not to respond

1d. Race (select all that apply)

☐ White ☐ Black/African American ☐ American Indian/Alaska Native ☐ Asian ☐ Native Hawaiian/Other Pacific Islander

1e. Hispanic or Latino? ☐ Yes ☐ No

1f. Disability ☐ Yes ☐ No

2. Household Members

2a. Total number of children living in the household (under age 18) ________

2b. Total number of adults living in the household (age 18 and older) ________

3. Family Income

3a. Total family income $_________________

3b. Family income group ☐ Extremely Low Income ☐ Very Low Income ☐ Low Income

4. Eviction Risk (select one category that best reflects circumstances at initial engagement)

☐ At risk of eviction ☐ Subject to eviction

5. Rental Housing Unit (at issue in the pending or potential eviction matter)

5a. Rental Housing Unit Physical Address

Number and Street ________________________________________________ Apt ________

City ________________________________ State ___________ ZIP code________________

County ______________________________

5b. Evicting Party _____________________________

5c. Is the Evicting Party a public housing agency (PHA)? ☐ Yes ☐ No

5d. Is the client’s rent for the unit listed in 5a subsidized by a federal housing program?

☐ HUD Public Housing ☐ HUD Housing Choice Voucher (Section 8) ☐ HUD Project-Based Section 8

☐ Low Income Housing Tax Credit (LIHTC) ☐ USDA Rural Housing ☐ Other ___________________

☐ No

5e. Has the client sought emergency rental assistance, such as Emergency Rental Assistance (ERA) program assistance?

☐ Yes, applied for assistance ☐ Yes, approved for or received assistance ☐ Yes, but denied assistance

☐ No

5f. Is the client’s mailing address at the time of initial engagement the same as the unit address listed in 5a?

☐ Yes ☐ No

B. Services Provided

6. Service Provider _____________________________

7. Primary Service (select one category that best reflects the level of service provided)

☐ One-on-one information at a court-based help desk

☐ One-on-one information via direct outreach or at a help center or hotline other than a court help desk

☐ Information or education in a group setting (i.e. presentation, workshop)

☐ Referral to a legal provider not affiliated with the program

☐ Referral to a non-legal service provider

☐ Limited counsel and advice

☐ Limited action/brief service

☐ Negotiated settlement without litigation

☐ Negotiated settlement with litigation

☐ Administrative agency decision

☐ Court decision

☐ Extensive service not resulting in settlement or court or administrative action

☐ Other pretrial activity

☐ Other trial activity

☐ Other post-trial activity

☐ Other alternative dispute resolution activity

☐ Other advocacy or activity to avoid litigation

8. Mediation Service (select all that apply)

☐ Mediation representation

☐ Mediated settlement agreement

9. Additional or Other Services Provided (briefly describe additional or other services provided)

______________________________________________________________________________

C. Outcomes

10. Outcomes (select all that apply)

☐ Prevented eviction filing

☐ Negotiated agreement or settlement

☐ Tenancy preserved, client remained in home

☐ Obtained additional days to move out (number of additional days _________ )

☐ Back rent reduced or waived

☐ Secured or maintained rental assistance

☐ Secured or maintained non-housing service or benefit

☐ Displacement without eviction judgement

☐ Eviction default judgement

☐ Eviction judgement (not default)

☐ Eviction delayed or stayed

☐ Eviction record sealed or expunged

☐ Avoided or reduced holdover damages, landlord attorney fees, or other costs

☐ Other

☐ Unknown

11. Additional or Other Outcomes (briefly describe additional or other outcomes)

______________________________________________________________________________

12. Case Duration Number of days engaged ________

Instructions for HUD Form 52698, Eviction Protection Grant Program

Client Services and Outcomes Report

1a. Unique client identification number assigned by the grantee.

1b. Client who, as a result of his, her, or their national origin, does not speak English as a primary language and who has a limited ability to speak, read, write, or understand.

1c. Select the category or categories that the client says best indicates the client’s gender identity. Select all that apply.

1d. Select the category or categories that the client says best indicates the client’s race. Select all that apply.

1e. Select one category that the client says best indicates the client’s ethnicity.

1f. Indicate whether or not the client has a disability.

2a. Indicate the total number of persons under age 18 living in the household.

2b. Indicate the total number of persons age 18 and older living in the household.

3a. Indicate the family’s total annual income.

3b. Select one category that represents the family’s income relative to the local area median income based on the number of persons in the household. See HUD’s income limits website.

4. Select one category that best reflects the client’s circumstances at the time of initial engagement.

At risk of eviction means the tenant: (1) has been given one or more formal or informal warnings by an Evicting Party, (2) has been notified by formal or informal means that the Evicting Party has commenced or intends to commence formal or informal eviction actions through the courts, self-help, or other means, or (3) is being harassed, threatened, discriminated against, neglected or treated differently than other tenants or other protected classes under the Fair Housing Act by the Evicting Party or the Evicting Party’s agents in a manner that appears calculated to result in the tenant’s vacating of the property.

Subject to eviction means: (1) the tenant has been notified that they will be removed from the property by a sheriff, marshal or other law enforcement or private agent enforcing a civil eviction order or engaging in self-help on behalf of the Evicting Party, (2) the tenant has been notified that they will be removed from the property by the Evicting Party or its agent, or (3) the Evicting Party has begun the eviction process pursuant to local law.

5a. Indicate the physical address of the client’s rental housing unit at issue in the pending or potential eviction matter. Include state and county at a minimum if other physical address details are unknown.

5b. Indicate the Evicting Party name in the pending or potential eviction matter with respect to the unit listed in 5a.

Evicting Party is a landlord, owner of a residential property, or other person or entity, including corporations, companies, associations, firms, partnerships, societies, joint ventures, joint stock companies, franchises and individuals, that has or purports to have a legal right to pursue eviction or possessory action.

5c. Indicate whether the Evicting Party listed in 5b is a public housing authority or agency (PHA).

5d. Indicate whether the client’s rent for the unit listed in 5a is subsidized by a federal housing program at the time of initial engagement. This information may be self-reported by the client if documentation or third-party confirmation of a federal housing subsidy is not available. Do not include short-term federal emergency rental assistance, such as Emergency Rental Assistance (ERA) program assistance in item 5d.

5e. Indicate whether the client has sought emergency rental assistance through the Emergency Rental Assistance (ERA) program or other emergency rent relief program. Select one category that best reflects the client’s circumstances at the time of initial engagement. This information may be self-reported by the client if documentation or third-party confirmation is not available.

5f. Indicate whether the client’s mailing address at the time of initial engagement is the same as the physical unit address listed in 5a.

6. Indicate name of grantee, subrecipient, or contractor providing service.

7. Select one category that best reflects the level of service provided at the time the matter is closed.

Limited counsel and advice means ascertained or reviewed facts, exercised judgment in applying relevant law, and counseled client concerning his, her, or their legal problem.

Limited action/brief service means communications to a third party, preparation of a simple legal document, or assisting a pro se client with preparation of court or other legal documents.

Negotiated settlement without litigation means resolved client’s problem through negotiation and settlement without any court or administrative actions pending.

Negotiated settlement with litigation means resolved client’s problem through negotiation and settlement while a court or formal administrative action was pending, including when the court or administrative agency issues an order memorializing the settlement.

Administrative agency decision means represented client in an administrative agency action that resulted in a case-dispositive decision by the administrative agency or body after a hearing or other formal administrative process.

Court decision means represented client in a court proceeding that resulted in a case dispositive decision made by the court.

Extensive service not resulting in settlement or court or administrative action means assistance involving high level of factual complexity, highly sophisticated legal analysis, drafting of non-routine original pleadings or legal documents, or significant legal research.

8. Select the category or categories that reflect mediation services provided during the client engagement, if any.

Mediation representation means represented client in a mediation process involving a trained, impartial third-party mediator, whether the decision to mediate was voluntary or ordered by a court.

Mediated settlement agreement means resolved client’s problem through negotiation and settlement and memorialized by a settlement agreement mediated by a trained, impartial third-party mediator, whether or not a court or administrative agency issues an order memorializing the settlement.

9. Briefly describe additional services provided. If applicable, briefly explain “Other” activity or advocacy.

10. Select the category or categories that represent client outcomes at the time the matter is closed. Select all that apply.

11. Briefly describe additional outcomes. If applicable, briefly explain “Other” outcomes.

12. Indicate the number of days the service provider listed in item 6 was engaged with the client in this matter, from the time of initial engagement to the time the matter is closed.

Form HUD-52698