Ingham County Housing Commission Mainstream Disabled Housing Choice Voucher (HCV) Program Application

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Rodney Williams
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1 Ingham County Housing Commission Mainstream Disabled Housing Choice Voucher (HCV) Program Application Please type or print clearly. Applications must be mailed to: Ingham County Housing Commission 3882 Dobie Road Okemos, MI Please read these instructions in their entirety. No exceptions to the instructions will be allowed. Only ONE application per household will be considered. Your application MUST be completely and accurately filled out for your entire household or you risk losing an opportunity to be on the waiting list. You must be a minimum of 18 years old to apply or an emancipated minor. All applications must be processed through the US Postal Service or hand delivered. Faxed copies will NOT be accepted. Applications will be assigned a date and time as they are received by this office. NOTE: If you wish to confirm that your application was received by this office, it is suggested you send it CERTIFIED/RETURN RECEIPT from your local post office ALL changes (i.e. address changes, household members, school, employment) MUST be submitted in writing. Privacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this information by the U.S. Housing Act of 1937 (42 U.S.C et. seq.), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and by the Fair Housing Act (42 U.S.C ). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants and participants to submit the Social Security Number of each household member. Purpose: Your income and other information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your family will pay toward rent and utilities. Other uses: HUD uses your family income and other information to assist in managing and monitoring HUD-assisted housing programs, to protect the Government s financial interest, and to verify the accuracy of the information you provide. This information may be released to appropriate Federal, State, and local agencies, when relevant, and to civil, criminal, or regulatory investigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law. Penalty: You must provide all of the information requested by the Housing Agent, including all Social Security Numbers you and all other household members have and use. Giving the Social Security Numbers of all household members is mandatory and not providing the Social Security Numbers will affect your eligibility. Failure to provide any of the requested information may result in a delay or rejection of your eligibility approval.

2 ICHC USE ONLY Preference: Residency? Yes No No. in Household Random # Name: Ingham County Housing Commission Housing Choice Voucher (HCV) Program Application Completion is required to apply for assistance. M / F First Name Middle Initial Last Name Male or Female Have You Ever used Another Name: Yes No, If Yes List Names: Married Divorced Widowed Single Address: Street Number Street Name Apt. # City State Zip Code Social Security No: Phone No: ( ) Area Code Drivers License #: Message Ph. No: ( ) Area Code Date of Birth: Place of Birth: City State - Country List All Persons Who Will Live With You: Note: Relationship to head such as son, daughter, nephew, niece, granddaughter, spouse, other adult, etc. SS Number Drivers License # Name Relation - ship 1) Date of Birth 2) 3) 4) 5) LIST ADDITIONAL HOUSEHOLD MEMBERS ON BACK List All Income Currently Received By All Household Members: All income: List total gross income (before taxes) and payments received by each family member age 18 or older for wages, military pay, pensions, social security, SSI, welfare, child support, Department of Human Services assistance, unemployment, business, profession, or any other source. Include payments made to family members age 18 or older on behalf of other family members under age 18. Source of Income Example: If employed, give name of employer Amount Example: $100 or 40 hours a $8.50 How Often Example: Weekly, biweekly, monthly Who Receives 1) 2) 3) 4)

3 LIST ADDITIONAL INCOME ON BACK List All Assets For All Household Members: Note: Assets include all checking, savings, stocks, bonds, certificates of deposits, real estate, etc. Type of Asset 1) Cash Value or Current Balance Interest Rate or Annual Income 2) 3) LIST ADDITIONAL ASSETS ON BACK Have you ever been on a rental assistance program or lived in public housing: If Yes, name of housing commission: Current Landlord: Landlord s Name/Management Company Landlord s Address: Street Number Street Name Apt. # City State Zip Code How much is your current rent: Are utilities included: Are you or your spouse disabled as per the Social Security Definition: If Yes, is the disability permanent or temporary: Do you or any member of your household have Legal Alien Status: If Yes, Name: ARN: Name: ARN: Are you or your spouse an honorably discharged Veteran: If Yes, what branch did you serve in and when: Are you or your spouse enrolled in school, such as college, trade, etc: If you or your spouse are employed, how long have you been employed: Have you or any other adult member of your household EVER been convicted of any crime other than a traffic violation: If Yes, explain: (Answering this question does not automatically disqualify you from Housing assistance) For statistical reporting, check all boxes that apply to Head of Household: ( ) White ( ) Black ( ) American Indian/Native Alaskan ( ) Asian/Pacific Islander ( ) Hispanic ( ) Non-Hispanic ( ) Other

4 I certify that the information given is true and complete to the best of my knowledge. I understand that receipt of this application does not obligate either party and does not guarantee acceptance into the Housing Choice Voucher Program. Housing may be contingent upon the submission and verification of evidence of citizenship or eligible immigration status prior to the time housing is made available. Based on evidence submitted at that time, assistance may be prorated, denied or terminated following appeals and informal hearing process. Further, I/We understand that failure to disclose all pertinent information to the best of my ability will be deemed fraudulent and will be turned over to the U.S. Department of Housing and Urban Development, Office of the Inspector General for appropriate action. I understand, also, that false statements or information are punishable under Federal Law by up to ten (10) years in prison and/or a $10,000 fine. I consent to release criminal conviction records including sexual offenses and alcohol abuse, pursuant to 24 CFR and allow Ingham County Housing Commission to receive records and use them in accordance with the U.S. Department of Housing and Urban Development regulations and Ingham County Housing Commission policy. I certify that I have not been evicted from any type of Section 8/Housing Choice Voucher Program or from Public or Indian Housing within the last three years due to drug related criminal activity, no member of my household has been convicted of manufacturing or producing methamphetamine on the premises of assisted housing, no member of my household has been evicted within the last five years from federally assisted housing. I will not receive Section 8 tenant-based assistance while receiving another housing subsidy, for the same unit or for a different unit, and all information contained in this application is true and complete to the best of my knowledge. I understand that Ingham County Housing Commission will screen adult applicants for drug-related and violent criminal activity including sexual offenses pursuant to 24 CFR and Ingham County Housing Commission policy. I, have read and understand all of the above and do hereby submit my application to the Ingham County Housing Commission. Signed this day of, 2013 Signature of Head of Household Signature of Spouse/Other Adult Mail Application to: Ingham County Housing Commission 3882 Dobie Road Okemos, MI Note: It is unlawful to pay for or sell Section 8 Applications. 2012/mld

5 AUTHORIZATION FOR RELEASE OF INFORMATION CONSENT: I authorize and direct any Federal, State, or local agency, organization, business, or individual to release to Ingham County Housing Commission any information or materials needed to complete and verify my application for participation, and/or to maintain my continued assistance under the Section 8, Rental Rehabilitation, Low-income Public and Indian Housing, and/or other housing assistance programs. I understand and agree that this authorization or the information obtained with its use may be given to and used by the Department of Housing and Urban Development (HUD) in administering and enforcing program rules and policies. INFORMATION COVERED: I understand that, depending on program policies and requirements, previous or current information regarding me or my household may be needed. Verifications and inquiries that may be requested include but are not limited to: Identity and Marital Status Employment, Income and Assets Medical Providers Residences and Rental Activity Credit and Criminal Activity Child Care Allowances I understand that this authorization cannot be used to obtain any information about me that is not pertinent to my eligibility for and continued participation in a housing assistance program. GROUPS OR INDIVIDUALS THAT MAY BE ASKED: The groups or individuals that may be asked to release the above information (depending on program requirements) included but not limited to: Previous Landlords (including Past and Present Employers Veterans Administration Public Housing Agencies) Welfare Agencies Retirement Systems Courts and Post Offices State Unemployment Agencies Banks & Financial Institutions Schools and Colleges Social Security Administration Credit Providers & Bureaus Law Enforcement Agencies Medical and Child Care Providers Utility Companies Support and Alimony Providers Pharmacies COMPUTER MATCHING NOTICE AND CONSENT: I understand and agree that HUD or the Public Housing Agency may conduct computer matching programs to verify the information supplied for my application or recertification. If a computer matching is done I understand that I have a right to notification of any adverse information found and a chance to disprove that information. HUD may in the course of its duties exchange such automated information with other Federal, State, or local agencies, including but not limited to: State Employment Security Agencies, Department of Defense: Office of personnel Management: the U.S. Postal Service; the Social Security Agency; and State Welfare and Food Stamp Agencies., CONDITIONS: I agree that a photocopy of this authorization may be used for the purposes stated above. This authorization will stay in affect for a year and three months from the date signed. SIGNATURES PRINTED/TYPED NAME DATE Head of Household: Adult/ Member: Adult Member: WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or Misrepresentation to any Department of Agency of the U.S. as to any matter within its jurisdiction.

6 Section 8 Mainstream Voucher Program What are mainstream program vouchers? Mainstream program vouchers enable families having a person with disabilities to lease affordable private housing of their choice. Mainstream program vouchers also assist persons with disabilities who often face difficulties in locating suitable and accessible housing on the private market. What families are eligible to apply for mainstream program vouchers? Only a family that includes a disabled person and is income eligible may receive a mainstream program voucher. Applicants will be selected from the Public Housing Authorities (PHA) housing choice voucher waiting list. How does a PHA determine if a family is income eligible for the mainstream program vouchers? The PHA compares the family s annual income (gross income) with the HUD-established very lowincome limit or low income limit for the area. The family's gross income cannot exceed this limit. How do families obtain an apartment once they have a voucher? It is the responsibility of a family to find a unit that meets their needs. If the family finds a unit that meets the housing quality standards, the rent is reasonable, and the unit meets other program requirements, the PHA executes a HAP contract with the property owner. This contract authorizes the PHA to make subsidy payments on behalf of the family. If the family moves out of the unit, the contract with the owner ends and the family can move with continued assistance to another unit How much rent do vouchers cover? The PHA pays the owner the difference between 30 percent of family income and PHA determined payment standard or gross rent whichever is lower. The family may choose a unit with a higher rent than the payment standard and pay the owner the difference. How do families obtain mainstream program vouchers? Families apply to the local PHA that administers this program. When an eligible family with a disabled person comes to the top of the PHAs housing choice voucher waiting list, the PHA issues a housing choice voucher to the family. * Link for local PHA:

7 OMB Control # Exp. (07/31/2012) Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING This form is to be provided to each applicant for federally assisted housing Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing, the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update, remove, or change the information you provide on this form at any time. You are not required to provide this contact information, but if you choose to do so, please include the relevant information on this form. Applicant Name: Mailing Address: Telephone No: Name of Additional Contact Person or Organization: Cell Phone No: Address: Telephone No: Address (if applicable): Cell Phone No: Relationship to Applicant: Reason for Contact: (Check all that apply) Emergency Unable to contact you Termination of rental assistance Eviction from unit Late payment of rent Assist with Recertification Process Change in lease terms Change in house rules Other: Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the issues or in providing any services or special care to you. Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the applicant or applicable law. Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law , approved October 28, 1992) requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or organization. By accepting the applicant s application, the housing provider agrees to comply with the non-discrimination and equal opportunity requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on age discrimination under the Age Discrimination Act of Check this box if you choose not to provide the contact information. Signature of Applicant Date The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C ). The public reporting burden is estimated at 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. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C ) imposed on HUD the obligation to require housing providers participating in HUD s assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in the application for occupancy the name, address, telephone number, and other relevant information of a family member, friend, or person associated with a social, health, advocacy, or similar organization. The objective of providing such information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any delivery of services or special care to the tenant and assist with resolving any tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and maintained as confidential information. Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and management controls that prevent fraud, waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless the collection displays a currently valid OMB control number. Privacy Statement: Public Law , authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be used by HUD to protect disbursement data from fraudulent actions. Form HUD (05/09)

APPLICATION WILL NOT BE ACCEPTED IF ANY DATA IS MISSING--COMPLETE BOTH SIDES. (Mailing Address)

APPLICATION WILL NOT BE ACCEPTED IF ANY DATA IS MISSING--COMPLETE BOTH SIDES. (Mailing Address) (410) 996-5245 (410) 658-4041 CECIL COUNTY HOUSING AGENCY SECTION 8 PROGRAM Office of Housing & Community Development 200 Chesapeake Blvd. Suite 1800 Elkton, Maryland 21921 FAX (410) 996-5256 TTY 1-800-735-2258