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Application for Admission and Rental Assistance
Section 8 Housing
Applicant Name
How did you hear about us?
Gender
Male
Female
Prefer not to disclose
Citizenship Status
United States Citizen
Eligible Non-Citizen
Ineligible Non-Citizen
What is your relationship to the Head of household?
Head of Household
* Co-head
* Spouse
Child
Other Adult
Foster Adult/Child
Live-in Aide (live in aides complete a different application and must be approved before move in)
None of the Above
Current Address
Address Line 2
City, State, Zip
Home Phone
Cell Phone
Email address
Work Phone
May we contact you at work?
Yes
No
Birth Date
Social Security Number
If you have no Social Security Number, you claim you are exempt beacuse
You are an ineligible non-citizen
You were 62 as of 1/31/10 and receiving HUD housing assistance as of 1/31/10
Are you enlisted in the U.S. Military or are you a veteran of the U.S. Military?
Yes
No
Are you a victim of a recent presidentially declared disaster?
Yes
No
Are you currently receiving housing assistance from HUD or a PHA?
Yes
No
Are you a student enrolled in an institute of higher education?
Yes
No
If yes
Full-time
Part-time
Are you currently using maijuana?
Have you ever been convicted of a crime?
Yes
No
If yes, indicated if the conviction(s) was a felony, misdemeanor or check both boxes if you have been convicted of both.
Felony
Misdemeanor
Are you or is any member of the household required to register with any state lifetime sex offender or other sex offender registry?
Yes
No
Have you ever been evicted from a federally funded housing program for lease violation including drug use or failure to report a crime?
Yes
No
If yes, when?
Please indicate each state where you have lived
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Washington D.C
Are you currently homeless? (If so skip questions about your current landlord and answer questions related to your most recent landlord)
Yes
No
If you are not the Head-of-Household (HOH), Is your current landlord the same as the HOH? (If Yes, continue to the Previous Landlord information: if No, Complete the Information below)
Yes
No
Current Landlord
Address
City, State, Zip
Contact Name (If Known)
Phone Number
How long have you lived at this address
Reason for Leaving
Were you ever asked to allow or participate in extermination of pests other than regularly scheduled pest control? (Includes roaches, bed bugs, rodents , etc.)
Yes
No
Do you currently have any outstanding overdue balances owed to this landlord?
Yes
No
Have you given this landlord notice that you will be moving?
Yes
No
Have you been evicted or is this landlord attempting to evict you or another person living with you?
Yes
No
Have you ever been asked to sign a repayment agreement to return money to HUD?
Yes
No
If you are not the Head-of-Household (HOH), is Previous Landlord #1 the same as the HOH? (If Yes, continue to the next section. If No, complete the Information below)
Yes
No
Previous Landlord #1
Address
Address
City, State, Zip
Contact Name (if known)
Phone Number
How long did you live at this address
Reason for leaving
Were you or any member of your household evicted from this property?
Yes
No
Were you ever asked to allow or participate in extermination of pests other than regularly scheduled pest control? (Includes roaches, bed bugs, rodents, etc.)
Yes
No
Did you owe the previous landlord any money when you left or do you currently have any outstanding balances owed to this landlord?
Yes
No
Have you ever been asked, by this landlord, to sign a repayment agreement to return money to HUD?
Yes
No
If you are not the Head-of-Household (HOH), is Previous Landlord #2 the same as the HOH? (If Yes, continue to the next section. If No, complete the Information below)
Yes
No
Previous Landlord #2
Address
City, State, Zip
Contact Name (if known)
Phone Number
How long did you live at this address
Reason for leaving
Were you or any member of your household evicted from this property?
Yes
No
Were you ever asked to allow or participate in extermination of pests other than regularly scheduled pest control? (Includes roaches, bed bugs, rodents, etc.)
Yes
No
Did you owe the previous landlord any money when you left or do you currently have any outstanding balances owed to this landlord?
Yes
No
Have you ever been asked, by this landlord, to sign a repayment agreement to return money to HUD?
Yes
No
Do you have any overdue/outstanding balances owed to any utility provider?
Yes
No
Will you be able to establish utilities in your unit? Electric
Yes
No
Do you receive any assistance to pay your utility bills?
Yes
No
Is assistance provided under the HHS Low-Income Home Energy Assistance Program (LEAP)?
Yes
No
N/A
If no, the monthly amount you receive to assist with your utility bills from other sources. (If none, type 0)
Do you plan to house an animal in the unit?
Yes
No
Is this animal required to live in the unit to alleviate the symptom(s) of a disability for a household member?
Yes
No
Animal Type (i.e. dog, cat, turtle, etc.)
Breed (if applicable)
Height (measured at withers if applicable)
Weight
If you are the Head of Household (HOH), please complete this section which provides information about other household members. Make a copy of this page if more than four people will live in the unit. This application must include information about everyone who will live in the unit. If you are not the HOH, please skip to questions about income and assets.
I am the Head of Household
I am not the Head of Household
Will anyone else live in the unit with you? If yes, please complete the following and note that all adults must complete their own application. If no, please skip to the next section.
Yes
No
How many people live in the unit?
MEMBER # & HOUSEHOLD MEMBER’S FULL NAME
Co-Head
Spouse
Child
Other Adult
Foster adult/child
Live-in Aide (live in aides must be approved before move in)
None of the Above
SSN
Date of Birth
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Washington D.C
The owner/agent will take your unit preferences/requirements in to consideration. The owner/agents occupancy standards indicate a minimum of one person per bedroom and maximum of two people per bedroom. Please indicate unit size preferences below. Please indicate any necessary special features below.
Unit Size
Studio Unit
1 Bedroom Unit
2 Bedroom Unit
3 Bedroom Unit
Special Features
Mobility Accessible Unit
Communication Accessible Unit (Hearing)
Community Accessible Unit (Visual)
Any other special features, please list below.
In order to determine eligibility and to ensure that your family receives the correct assistance, please provide the following information.
Are you employed?
Yes
No
If yes, please provide the name and address of your present employer below.
Phone
How much employment income do you expect to receive in the next 12 months?
Do you currently have more than two employers?
Yes (please provice more information below)
No
How much do you expect to receive in other income in the next 12 months? Please write in 0.00, NA or None if you will receive no income from these sources. THE OWNER/AGENT WILL NOT PROCESS THE APPLICATION IF THESE FIELDS ARE NOT COMPLETE.
Monthly Social Security
Check
Direct Deposit
Pre-Paid Debit Card
None
Monthly SSI?
Check
Direct Deposit
Pre-Paid Debit Card
None
Monthly Retirement Benefits?
Check
Direct Deposit
Pre-Paid Debit Card
None
Monthly VA Benefits?
Check
Direct Deposit
Pre-Paid Debit Card
None
Monthly Unemployed Benefits?
Check
Direct Deposit
Pre-Paid Debit Card
None
Are you entitled to child support?
Check
Direct Deposit
Pre-Paid Debit Card
None
Yes
No
Monthly Child Support Amount
Are you entitled to Alimony?
Yes
No
Monthly Alimony Amount
Monthly Public Assistance?
Check
Direct Deposit
Pre-Paid Debit Card
None
Income from a pension or annuity or other asset?
Regular contributions from organizations or from individuals not living in the unit?
Periodic Payments from Long-Term Care Insurance, Disability, or Death Benefits?
Contributions from family or other sources for rent, child care or other bills.
Any lump sum amounts from delay of payments for SSI or VA Disability
Do you receive financial aid for education assistance?
Yes
No
Annual amount of education assistance.
Other?
Have you disposed of any assets for less than fair market value 2 years prior to the certification or recertification date?
Yes
No
Have you given any money to charities in the past two years?
Yes
No
Are any benefits deposited in to a Direct Express Debit Card account?
Yes
No
Do you have a checking account? If YES, what Bank?
Yes
No
Do you have a checking account? If YES, what Bank? If NO, type N/A
Current Balance - Please write in 0.00, NA or None if the asset value is zero.
Do you have cash that is not deposited in an account?
Yes
No
Current Value - Please write in 0.00, NA or None if the asset value is zero.
Do you have a 401K or other employment savings account? If YES, what bank? If NO, type N/A
Current Value - Please write in 0.00, NA or None if the asset value is zero.
Do you own an IRA or other retirement account? If YES, what bank? If NO, type N/A
Current Value - Please write in 0.00, NA or None if the asset value is zero.
Do any of your retirement accounts have a Required Minimum Distribution?
Yes
No
Amount
Do you own a home or other property?
Yes
No
Current Value- Please write in 0.00, NA or None if the asset value is zero.
Do you have business income?
Yes
No
Current Value of Business - Please write in 0.00, NA or None if the asset value is zero.
Do you own stocks/bonds/certificates of deposit (CD)? If YES, what bank? If NO, type N/A
Current Value - Please write in 0.00, NA or None if the asset value is zero.
Do you own a life insurance policy?
Yes
Whole
Term
Universal
No
Current Value - Please write in 0.00, NA or None if the asset value is zero.
Do you own an annuity? If YES, what company? If NO, type N/A
Current Value - Please write in 0.00, NA or None if the asset value is zero.
Is there a trust fund in your name or have you established a trust fund for someone else?
Yes
No
Current Value - Please write in 0.00, NA or None if the asset value is zero.
Do you have a safety deposit box?
Yes
No
Are assets stored in the safety deposit box such as US Savings Bonds, cash, stocks, etc.
Yes
No
Do you have access to any other assets, property, insurance policies, businesses, etc.?
Yes
No
If yes, please provide a description of the asset(s) and the current asset value below:
HUD allows you to deduct a certain amount of child care expense to allow a resident living in the unit to work, look for work or to go to school. Please indicate any child care expense for any child who is 12 years of age or younger. Expenses for children 13 or older are not allowed as part of the deduction unless the child is disabled and such expense is necessary to allow an adult household member to work. See Disability Assistance Expense below.
Do you pay for Child Care for a minor 12 years of age or younger?
Yes
No
Child #1 Name:
Enables someone to:
Work
Seek Employment
Go to school
Monthly Amount
Child #2 Name:
Enables someone to:
Work
Seek employment
Go to school
Monthly Amount
Child #3 Name:
Enables someone to:
Work
Seek employment
Go to school
Monthly Amount
Families are entitled to a deduction for unreimbursed, anticipated costs for attendant care and “auxiliary apparatus” for each family member who is a person with disabilities, to the extent these expenses are reasonable and necessary to enable any adult to be employed. The deduction may not exceed the earned income received by the family member or members who are enabled to work by the attendant care or auxiliary apparatus
Do you pay for care or expenses for a disabled family member that allows any adult family member to work?
Yes
No
Monthly Amount
Name of Family Member who can work as a result of such an expense.
Do you pay for equipment that allows any adult family member to work? e.g. costs to equip a vehicle to make it accessible in order to allow a disabled member to drive to work
Yes
No
Monthly Amount
Name of Family Member who can work as a result of such an expense.
Households in which the head-of-household, co-head of household or spouse are disabled or at least 62 years old qualify for deductions based on out-of-pocket medical expenses. Please let us know if you or any members of your household have out-of-pocket expenses for the following:
Health Insurance – (1– annual premium) If YES, what Company? If NO, type N/A
Health Insurance – (1 – annual deductible)
Health Insurance – (2 – annual premium) If YES, what Company? if NO, type N/A
Dr. visit/medical treatments - annual out-of-pocket expense
Prescription Drugs - annual out-of-pocket expense
Do you have an HMO, a medical plan, or health insurance policy, which pays all or part of the cost of your medications? If Yes, what Company? If NO, type N/A
What amount (or percentage) of the cost must YOU pay?
If you must pay for the medicines yourself, are you later reimbursed all or part of the cost?
Yes
No
If yes, who reimburses you? Additional medical information may be added to a blank piece of paper an attached to this application.
Over-the-counter medical expenses to treat a specific medical condition - annual out-of-pocket expense (i.e. aspirin to treat a heart condition or calcium supplements to treat osteoporosis)
Personal use items annual out-of-pocket expense
Cost/Care for Assistance/Companion Animals - annual out-of-pocket expense
Mileage to and from medical appointments
Other
Other
Are there any other medical expenses, which you pay, that we should consider when calculating your rent?
Other?
Other?
Other?
Please list what out of pocket expenses have you paid in the last 12 months from Doctors, Eye Doctor, and Dentists, Pharmacies, any Hospital or any other Medical Facility?
Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government, HUD, the PHA and any owner (or any employee of HUD, the PHA or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposes cited above. Any person who knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the PHA or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Act at 208 (a) (6), (7) and (8). Violation of these provisions are cited as violations of 42 U.S.C. 408 (a) (6), (7) and (8).
By signing this document, I certify that if selected to receive assistance, the unit I/we occupy will by my/our only residence. I/we understand that the above information is being collected to determine my/our eligibility. I/we authorize the owner/manager/PHA to verify all information provided on this application and to contact previous or current landlords or other sources of credit and verification information which may be released to appropriate Federal, State, or local agencies. I/we certify that the statements made in the application are true and complete. I/we understand that providing false statements or information is punishable under Federal Law. By signing this application I/We acknowledge receipt of the following HUD informational publications: “Resident Rights and Responsibilities”, “EIV & You Brochure”, “Fact Sheet” (How Your Rent is Determined); and “Applying for HUD Housing Assistance Pamphlet”. I would like to request a complete copy of the owner/agents resident selection criteria.
No
Yes
If yes, which option do you prefer?
Paper Copy
Electronic Copy
Type E-Signature and Date
MARYVALE does not discriminate on the basis of disability status in the admission or access to, or treatment or employment in, its federally assisted programs and activities. The person named below has been designated to coordinate compliance with the nondiscrimination requirements contained in the Department of Housing and Urban Development’s regulations implementing Section 504 (24 CFR, part 8 dated June 2, 1988). Yvonne Avary 711 Ohio Street Terre Haute, IN 47802 Telephone – 812-232-5083 TDD Telephone 1-800-545-1833 ext 490
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