Accessible/Plain Language Residency Agreement Sample

MY RESIDENCY AGREEMENT

Definitions: What do the words in this document mean?

  • Residency Agreement: A contract between you and your provider/landlord. It says what you can and cannot do, especially that you have to try to take good care of your home. It also says what your provider/landlord has to do to protect your rights.
  • Contract: An agreement that people have to follow (it is enforceable by law).
  • Tenant: You!
  • Property: The home you live in.
  • Landlord: This is the person who owns your home. They have to make sure your home is safe for you to live in.
  • Rent: The money you pay to your landlord so you can live there. Your rent may also include some of the utilities.
  • Utilities: Gas, water, electricity, sewage, trash/recycling removal, home phone (not cell phones), cable, internet
  • Privacy: time alone, when people are not watching or listening to you or what you are doing
  • Appeal: request that the State government take a look at the provider/landlord's decision to terminate services. You might get help from your support coordinator if this happens.
  • Terminate: end or stop
  • Modification: to make changes or restrict/limit someone's rights
  • Informed consent: when you agree to something after you have all the information you need to make a decision. For example, if you give permission for a rights modification, you are saying you are okay with the modification and you understand the risks and benefits of the modification. If you do not give permission for a rights modification, you are saying you are not okay with the modification OR that you do not understand the risks and benefits. You do not have to give informed consent or give the provider permission to modify your rights.
  • Representative payee: a person that is selected to help you with the money you get from the Social Security Administration (the federal government)
  • Provider: the organization that helps support you

Agreement: This residency agreement is between you, your guardian if you have one, and your provider/landlord.

Your address is: ___________________________________________________

Optional: Click The Box Below To Insert Photo Of The Person's Home

You will be renting:

  • The whole house on your own.
  • Your own bedroom in a shared house with others.

Your bedroom is:______________________ (insert photo)

Your housemates are:______________________ (insert photos)

  • A shared bedroom in a shared house with others.

Your bedroom is:______________________ (insert photo)

Your roommate is:______________________ (insert photo)

Your housemates are:______________________ (insert photos)

  • Room in someone else's home who provides you with support.

Rent: You are renting your house/bedroom starting on [INSERT DATE]. This agreement ends on [INSERT DATE].

Your rent each month costs: $_______________. This includes:

  • Utilities: circle those that are paid for by the landlord/organization
    • Gas
    • Water
    • Sewer
    • Electric
    • Cabl
    • Internet
  • Food:____________________________________________________________________
  • Other:____________________________________________________________________

You must pay this money to your provider/landlord by [INSERT DATE] every month, starting on [INSERT DATE]. If you have a representative payee, they will help you pay your rent on time.

Your representative payee is: _______________________________________________

Optional: Insert Photo Of The Representative Payee

Please send your rent to: 

You do not have to choose the provider/landlord to be your representative payee to rent a home from your provider/landlord or to get services from them.

Your rent charges will not change unless your landlord/provider updates this agreement with you.

Rights and Responsibilities:

You have the right to:

  • Access (be able to use) all parts of your home, except for other people's bedrooms. If you need to have changes made to your home so you can access everything, your provider should help you.
  • Privacy where you sleep.
  • Privacy while talking on the phone or using the computer.
  • Privacy while using the bathroom.
  • A key (or another method like a fob or keypad or keycard if that works better for you) to lock and unlock your house and bedroom.
  • Choose who you live with.
  • Decorate your bedroom. (Be sure to follow the rules in your residency agreement - some landlords will not let you paint or put nails in the wall, for example. Some may let you do it but ask that you fix it back to the way it was if you ever move out).
  • Decorate the rest of your home. If you live with other people, you'll need to decide together how to decorate the shared spaces.
  • Decide when to get up, go to bed, and how to spend your time.
  • Spend time in your community.
  • Eat whenever yvou want.
  • Have visitors over whenever you want. You might discuss this with your housemates if you have any to make sure their rights are respected. You have the right to have privacy with your visitors.
  • Share your concerns, complaints, or feedback with the provider/landlord about your house and your services.
  • Choose who helps you manage your money, or you can choose to manage your money on your own.

You have the responsibility to:

  • Make sure your living space isn't harmful to yourself or your housemates (if you have them).
  • Not damage the property.
  • Not harm your housemates (if you have them) with your actions or words.
  • Not disturb your housemates (if you have them). You may want to talk with your housemates about things that they are bothered by and tell them the things that would bother you.
  • Respect your housemates' (if you have them) privacy and rights.
  • Pay your rent on time.

Your provider/landlord must:

  • Keep your home in good repair.
  • Make sure your heating, plumbing, and lighting works.
  • Tell you when they are going to do repairs (and let you know far enough in advance for you to get ready for them to come).

If your provider/landlord needs to modify (change or limit or remove) any of your rights, they must:

  • Have the modification personalized to you and what you need to be successful
  • Show that positive interventions and supports have been tried first
  • Prove that less intrusive methods have been tried but didn't work
  • Keep data and other information and measure it to see if the modification is effective!
  • Show that any modification is TEMPORARY and won't last forever - review regularly to see if it is still needed. They should make sure you know what you are supposed to do to get your right(s) back!
  • Get informed consent from YOU! They will also need to get informed consent from your guardian if you have one.
  • Show the modification will cause no harm.
  • Document (put in writing) all of this information about the modification and share a copy with you.

If you choose to move:

  • You should talk to your ISC (some people call them a case manager or support coordinator) to make plans. They can help you tell your provider/landlord your plans.
    • You ISC (support coordinator) is:

 Optional: Insert Photo Of Your Support Coordinator

  • Your provider/landlord needs to continue to provide supports you need in your home until you move and make sure your new provider gets the information they need to support you.

If your provider/landlord no longer wants you to live in the home or cannot provide you supports, they must:

  • Tell you, your guardian if you have one, and your ISC case manager / support coordinator. They must give you this information in writing.
  • They must tell you 60 days before they want you to move out.
  • They must tell you in writing why they can't serve you anymore.
  • They must tell you in writing everything they have tried to successfully support you.
  • They must give you the information about Illinois Rule 115. This rule is about your right to appeal termination (ending) of services.
  • They must follow their own policies about "grievances" (how people can file complaints or concerns).
  • They must follow their own policies about "temporary service suspension" (if they stop providing you with services for a little while) and "service termination" (if they end your services) and Rule 115 (the rules the state says the provider must follow if they support people in community integrated living arrangements (CILA) - like the home you are in).

Signatures:

Person (you!)   Date

Your guardian (if you have one)  Date

Witness (friend/ally/someone you trust) (optional) Date

Program representative (provider/landlord)  Date

Your landlord should give you a copy of this rental agreement once it is signed.

In partnership with the Illinois Council on Developmental Disabilities. This project was supported, in part by grant number CFDA 93.630, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects with government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official ACL policy.