2. Applicant Name:*
3. MAXIS Case Number:
4. Date of Birth:
   Date of Birth:
6. County:*
7. Financial Worker:
8. Phone/ Fax Number:*
10. Address of Housing Unit:
12. City:*
13. State:*
14. Zip Code*

16. Group Residential Housing (GRH) supportive housing settings must have an approved habitability inspection. The habitability inspection will determine whether the housing occupied by the GRH recipients meets the Department of Human Services’ habitability standards.

18. Inspector:

        Check “Approved” or “Deficient” for each standard on the back of this form, and describe any deficiencies in comments section at the bottom of the page.

        Complete the certification statement below.

        Assist GRH applicant as needed in submitting this form to the financial worker listed above.

        Give a copy of this completed form to the GRH applicant.

20. Certification Statement:

    I certify that I have evaluated the property located at the address above, and to the best of my ability find: 

        Property meets all of the habitability standards. Unit is approved for GRH funding.

        Property does not meet all of the habitability standards. Unit is not approved for GRH funding.

    
    

22. Inspectors Name:*
23. Inspectors Agency:*
24. Phone Number:*
26. Date/ time of Inspection:*
    Date/ time of Inspection:

    Date/ time of Inspection:
27. Inspection type:*
    -- Select One --InitialRe-Inspection
29. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
31. Inspector Electronic Signature *
33. Will unit be re-inspected?*
    -- Select One --YesNo
35. Plans and timelines to improve conditions:
37. Planned re-inspection date:
    Planned re-inspection date:

39. When this form will be emailed to the Housing Program Team upon submission, it will be provided to the financial worker listed above. GRH benefits cannot be approved until this form is received. 

41. Habitability Inspection Standards:
43. 1. Structure and Materials:*
    -- Select One --ApprovedDeficient

    The building appears structurally sound, appears to protect the residents from the elements and does not appear to pose any threat to the health and safety of the residents.

44. 2. Space and security:*
    -- Select One --ApprovedDeficient

    Each resident is provided adequate space and security for themselves and their belongings.  Each resident is provided an acceptable place to sleep. 

46. 3. Interior air quality:*
    -- Select One --ApprovedDeficient

    Each room or space has a natural or mechanical means of ventilation.  The interior air appears to be free of pollutants.

47. 4. Water Supply:*
    -- Select One --ApprovedDeficient

    The water supply appears to be clean and safe. All plumbing fixtures and drains appear to be in proper operating condition.

49. 5. Sanitary Faclities:*
    -- Select One --ApprovedDeficient

    Residents have access to sufficient sanitary facilities that appear to be in proper operating condition, are private, and are adequate for personal cleanliness and the disposal of human waste.

50. 6. Thermal Enviroment:*
    -- Select One --ApprovedDeficient

    The housing has any necessary heating facilities which appear to be in proper operating condition.

52. 7. Illumination and Electricity:*
    -- Select One --ApprovedDeficient

    The structure has adequate natural or artificial illumination to permit normal indoor activities and support health and safety. There are sufficient electrical sources to permit the safe use of electrical appliances in the structure.

53. 8. Food preparation:*
    -- Select One --ApprovedDeficient

    All food preparation areas contain suitable space and equipment to store, prepare, and serve food in a safe and sanitary manner.

55. 9. Sanitary conditions:*
    -- Select One --ApprovedDeficient

    The housing is maintained and appears to be in sanitary condition.

56. 10. Fire Safety:
    -- Select One --ApprovedDeficient

    a.    There is a second means of exiting the building in the event of fire or other emergency.

    b.    The unit includes at least one battery-operated or hard-wired smoke detector, in proper working condition, on each occupied level of the unit.  Smoke detectors are located, to the extent practicable, in a hallway adjacent to a bedroom.

    c.    If the unit is occupied by hearing-impaired persons, smoke detectors have an alarm system designed for hearing-impaired persons in each bedroom occupied by a hearing-impaired person.

    d.    The public areas are equipped with a sufficient number, but not less than one for each area, of battery-operated or hard-wired smoke detectors.  Public areas include, but are not limited to, laundry rooms, hallways, stairwells, and other common areas.

58. Comments (Locations and details of deficiencies):

60. 651-431-3941

    
    

    Attention. If you need free help interpreting this document, call the above number.

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    kMNt’sMKal’ . ebIG~k¨tUvkarCMnYyk~¬gkarbkE¨bäksarenHeday²tKit«f sUmehATUrs&BÍtamelxxagelI .

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    ces hu rau tus najnpawb xov tooj saum toj no. 

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    Digniin. Haddii aad u baahantahay caawimaad lacag-la’aan ah ee tarjumaadda qoraalkan, lambarka kore wac.

    Atención. Si desea recibir asistencia gratuita para interpretar este documento, llame al número indicado arriba.

    Chú ý. Nếu quý vị cần được giúp đỡ dịch tài liệu này miễn phí, xin gọi số bên trên.

    
    

    
    

    This information is available in accessible formats for individuals with disabilities by calling 651-431-3941 or by using your preferred relay service. For other information on disability rights and protections, contact the agency’s ADA coordinator.

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