Application Packet - Aberdeen, Mississippi Housing Authority

Transcription

ABERDEEN HOUSING AUTHORITY
APPLICATION PACKET
APPLICATION PACKET
REVISED: MARCH 2010, APRIL 2015
1
PLEASE READ CAREFULLY BEFORE APPLYING
The paperwork you are submitting is only for Public Housing Assistance through the Aberdeen Housing
Authority. In order for your application to be processed, the application MUST include the following
information:
 Name and complete mailing address of your most recent landlord(s)
o Must include the street name and house (apartment) number or County road number and house
(apartment) number; or Post Office Box Number along with the City, State, and Zip Code. You
must include the telephone number(s) of your most recent landlord(s).
The Aberdeen Housing Authority (hereinafter referred to as the AHA) is required by law to verify ALL family
income. The AHA has the ability to obtain wage information through State Wage databases, Social
Security benefits through the Social Security Administration databases, any unemployment
compensation, and any pensions for each person in your household. You must provide the AHA with your
employer’s name, complete mailing address, and telephone number if you are currently employed, any or
support payments (monetary or non-monetary) to your household, any income you receive on a continuing basis
(you must report the names, addresses, and telephone numbers of these types of income sources). If you are
receiving Social Security Benefits, Supplemental Security Income, Veteran Administration benefits,
Unemployment benefits, or any other type of payment based on your inability to work, you must provide the
AHA with a copy of your award(s) letter.
You MUST provide the AHA with a clear photocopy of your Social Security Card and Birth Certificate for all
household members, regardless of age. We cannot process your application for housing assistance without
the Social Security Card or Birth Certificate documents for all family members.
All applicants and household members (years 18 and older) must not have any violent crime or drug charges
within the past five (5) years. The AHA will perform a criminal background check on all family members that
are 18 years of age and older.
If you are legally separated or claim divorced status, you must provide the AHA with a copy of your final
divorce decree or legal separation papers.
In order to be eligible for a deduction from your total annual income in the amount of Four Hundred and Eighty
Dollar ($480.00), which is designed by the U. S. Department of Housing and Urban Development (HUD).as a
dependent deduction, your “dependent(s)” must be under the age of 18, or if over 18 years of age is a full-time
student or is a person with a disability. If the dependent(s) is 18 years of age or older, you must provide the
AHA with the school’s name, complete address, telephone number, and a copy of the students school record
that proves they are designed as a full-time student. The AHA must verify this dependent information before a
dependent deduction can be granted to any household member. Dependents that are subject to joint custody
arrangements will be considered a member of the family if they live with the applicant or resident family fifty
percent (50%) or more of the time in a twelve (12) month period. Legal custody of dependents must be
evidenced by a legal court order granting the custody of the dependent to the head of household or other adult
family member of the family household.
If you (the head of the household, spouse, or co-head) is employed, are actively seeking gainful
employment, or seeking to further their continuing education, you may eligible for a child care deduction.
HUD defines child care expenses as “amounts anticipated to be paid by the family for the care of children
under 13 years of age during the period for which annual income is computed, but only where such care
is necessary to enable a family member to actively seek employment, be gainfully employed, or to further
his or her education and only to the extent such amounts are not reimbursed to the family.” The amount
deducted shall reflect reasonable charges for child care.
If you, as the head of household, spouse, co-head, or sole member of the household, is age 62 years of age or
older, handicapped, and/or disabled, you may be eligible for a Four Hundred Dollar ($400.00) single
deduction. If you meet these qualifications, please provide the AHA with copies of your unreimbursed medical
expenses for the upcoming 12-month period and with any reasonable expenses for any attendant care and/or
auxiliary apparatus for the disabled family member.
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We appreciate your interest in our housing communities.
WE TRY TO PROCESS EVERY APPLICATION IN AN EXPEDIENT MANNER. THE AHA WILL
PROCESS YOUR APPLICATION AS SOON AS WE RECEIVE YOUR LANDLORD REFERENCES,
POLICE BACKGROUND CHECK, CREDIT CHECK, AND INCOME AND EXPENSE
VERIFICATION. IF YOUR APPLICATION IS INCOMPLETE, A LETTER WILL BE SENT TO
YOU STATING THE ITEMS NEEDED FOR FURTHER PROCESSING, AND WILL INCLUDE A
DEADLINE DATE FOR RETURN OF THE MISSING ITEMS TO THE AHA. THE AHA WILL
CONTACT YOU ONCE WE HAVE RECEIVED AND VERIFIED ALL OF YOUR INFORMATION
REGARDING ELIGIBILITY. FREQUENT CALLS FROM APPLICANTS ONLY SLOWS DOWN
THE PROCESSING OF YOUR APPLICATION, SO PLEASE BE PATIENT.
WHEN THE AHA NOTIFIES THE PUBLIC THAT APPLICATIONS FOR HOUSING ASSISTANCE
ARE BEING ACCEPTED, YOU MAY MAKE APPLICATION ON TUESDAY, WEDNESDAY, AND
THURSDAY FROM 9:00 AM THROUGH 3:30 PM.
IF YOU ARE AN APPLICANT WITH A HANDICAP AND/OR A DISABILITY AND A SPECIAL
ACCOMMODATION IS NEEDED, PLEASE BE SURE AND ADVISE THE AHA STAFF PERSON
THAT YOU REQUIRE A SPECIAL-NEEDS DWELLING UNIT.
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NOTICE TO ALL APPLICANTS
TO BE ELIGIBLE FOR ADMISSION, AN APPLICANT MUST QUALIFY AS A FAMILY. A FAMILY
MAY BE A SINGLE PERSON OR A GROUP OF PERSONS. FAMILY AS DEFINED BY HUD
INCLUDES BUT IS NOT LIMITED TO, REGARDLESS OF MARITAL STATUS, ACTUAL OR
PERCEIVED SEXUAL ORIENTATION, OR GENDER IDENTITY, THE FOLLOWING: 1. A SINGLE
PERSON, WHO MAY BE AN ELDERLY PERSON, DISPLACED PERSON, DISABLED PERSON,
NEAR-ELDERLY PERSON, OR ANY OTHER SINGLE PERSON OR 2. A GROUP OF PERSONS
RESIDING TOGETHER, AND SUCH GROUP INCLUDES, BUT IS NOT LIMITED TO: (I) A
FAMILY WITH OR WITHOUT CHILDREN (A CHILD WHO IS TEMPORARILY AWAY FROM
THE HOME BECAUSE OF PLACEMENT IN FOSTER CARE IS CONSIDERED A MEMBER OF
THE FAMILY); (II) AN ELDERLY FAMILY; OR (III) A NEAR-ELDERLY FAMILY; (IV) A
DISABLED FAMILY; (V) A DISPLACED FAMILY AND (VI) THE REMAINING MEMBER OF A
TENANT FAMILY.
EACH FAMILY MUST IDENTIFY THE INDIVIDUALS TO BE INCLUDED IN THE FAMILY AT
THE TIME OF APPLICATION, AND MUST UPDATE THIS INFORMATION WITH THE AHA IF
THE FAMILY’S COMPOSITION CHANGES AT ANY TIME.
THE HEAD OF HOUSEHOLD OF THE FAMILY MUST HAVE THE LEGAL CAPACITY TO
ENTER INTO A DWELLING LEASE UNDER STATE LAW (LEGAL AGE BEING AT LEAST
TWENTY-ONE (21) YEARS OF AGE OR OLDER OR AN EMANICIPATED MINOR). AN
EMANICAPTED MINOR IS ONE WHO HAS BEEN GRANTED LEGAL (THROUGH A COURT OF
LAW) EMANICIPATION UNDER MISSISSIPPI STATE CODE 1972 SECTION 93-19-1, ET. SEQ.
ALL MEMBERS OF THE HOUSEHOLD MUST PROVIDE APPROPRIATE DOCUMENTATION OF
HIS/HER SOCIAL SECURITY NUMBER AND A VALID BIRTH CERTIFICATE BEFORE THE
FAMILY CAN BE ADMITTED TO THE PROGRAM.
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THE ABERDEEN HOUSING AUTHORITY
ELIGIBILITY REQUIREMENTS
1. Income must fall within the allowable income limits as published by the U. S. Department of
Housing and Urban Development, which is applied only at admission to the program.
2. Must meet the Aberdeen Housing Authority’s Suitability Requirements, which are:
a. Acceptable credit check
b. Favorable Landlord check
c. Favorable references
d. Must not owe the Aberdeen Housing Authority or any other PHA any unpaid charges
(rent, maintenance charges, damages, etc.)
e. Must pass “One Strike” screening criteria.
3. Family must meet citizenship requirements.
4. Must sign a consent form (HUD 9886, Release of Information) (all persons 18 years of age and
older are required to sign this Release form)
5. Other factors: All family members must provide their Social Security cards and birth certificates.
No person will be housed until these items are presented to the Aberdeen Housing Authority. In
the absence of a birth certificate or a social security card, the applicant will be required to apply
for a replacement for these documents, but in no instance will you be housed until we receive these
documents.
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PRE-APPLICATION APPOINTMENT
DATE: ________________________
NAME: ________________________________________________________________
ADDRESS: ____________________________________________________________
TELEPHONE NUMBER: ________________________________________________
NUMBER OF BEDROOMS REQUIRED: __________________________________
FAMILY SIZE: ______________
NUMBER OF ADULTS: _____________ NUMBER OF CHILDREN: __________
CURRENT INCOME SOURCES: _________________________________________
_____________________________________________________________
_____________________________________________________________
APPOINTMENT INFORMATION
DATE OF APPOINTMENT: _______________________________________________
TIME OF APPOINTMENT: ________________________________________________
AHA STAFF SIGNATURE: ________________________________________________
APPOINTMENT KEPT: YES [ ]
NO [ ]
REASON APPOINTMENT MISSED: ________________________________________
_________________________________________________________________________
APPOINTMENT RESCHEDULED: YES [ ] NO[ ]
RESCHEDULE DATE: ____________________________________________________
RESCHEDULE TIME: ____________________________________________________
COMMENTS: ____________________________________________________________
_________________________________________________________________________
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910 Martin Luther King Street, Aberdeen, MS 39730
(662) 369-9460
PRE-APPLICATION
PERSONAL DECLARATION
NAME _____________________________________________________________________________________
ADDRESS ___________________________________________________________________________________
PHONE NO. ________________
RACE: ______________ (1=WHITE; 2=BLACK; 3=AMERICAN INDIAN/ALASKAN; 4=ASIAN; 5=HAWAIIAN/PACIFIC ISLANDER; 6=MIXED)
THIS FORM MUST BE COMPLETED IN YOUR OWN HANDWRITING. YOU MUST USE THE CORRECT LEGAL NAME FOR
EACH MEMBER OF YOUR HOUSEHOLD AS IT APPEARS ON THE SOCIAL SECURITY CARD. PLEASE PRINT LEGIBLY, AND
HAVE THE BACK OF THIS FORM NOTARIZED.
I. HOUSEHOLD COMPOSITION: List all persons who will be living in your home, listing Head of Household first.
HOUSEHOLD MEMBERS (Legal Name)
AGE
RELATION
TO HEAD
DATE OF
BIRTH
SOCIAL SECURITY NUMBER
HEAD
MARTIAL STATUS/HISTORY: Have you ever been married? _______ How many times? _______
Maiden Name_______________________________________________________________
(If separated or divorced, list name, address, and social secutity number of spouse/ex-spouse)
FROM WHOM
STREET ADDRESS
CITY/STATE/ZIP
SOCIAL SECURITY NUMBER
Full-Time Student Information: List all family member names, school name, school address, and telephone number for
all family members who are attending school full-time.
Social Security Number
Children
(Name as it appears on Date of Birth
SS Card)
School Name
School Address
Phone
Relation
to
Head
II. TOTAL HOUSE INCOME: List all money earned or received by everyone living in your household. This includes money from
wages, self-employment, child support, (family and non-family) cash contributions, Social Security, disability payments (SSI),
Workman’s Compensation, retirement benefits, TANF, Veterans benefits, rental property income, stock dividends, oil royalties,
interest from bank accounts, alimony, and any non-cash contributions.
Household
Member
Employer
Child
Support
Monthly
TANF Monthly
Social
Security
Monthly
Unemployment
Benefits Monthly
Other Income
Monthly
Medical Expenses: For elderly families and/or disabled families whose head or spouse is a person with a disability. Medical
expenses are those that are anticipated during the 12 month period for which annual incme is computed and that are not covered by
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insurance. Allowable medical expenses may include: services of doctors and health care professionals; services of health care
facilities, medical insurance premiums, prescription/non-prescription medicines (prescribed by a physician); transporation to
treatment; dental expenses, eyeglasses, hearing aids and batteries; line-in or periodic medicial assistance; and monthly payment on
accumulated medical bills (but only for the amount expected to be paid in the coming 12-months).
Household
Member
Relation to Head
Social Security Number
Type of Expense
Anticipated Yearly
Expense
Child care Expenses: Does any family member pay child care expenses during the period for which annual income is computed? ( )
Yes ( ) No. If yes, is the child (children) under the age of 13? ( ) Yes ( ) No. If yes, is the care necessary to enable a family
member to: actively seek employment, be gainfully employed, or further his/her education? All child care expenses MUST not be
reimbursed to the family member in order to be excluded from annual income.
Child care expense deductions may not
exceed the amount of employment income included in the annual income. NOTE: Fraudulent reporting of child care expenses
is a serious violation. All child care expenses reported to the Authority is subject to being reported to the Internal Revenue
Service as taxable income.
Household
Member
Social Secuity Number
Child Care Provider and Address
Gross Monthly Wages
Amount of Child Care
Expense
III. ASSETS. A “yes” answer to any item(s) on the list below, will be counted as asset income.
1. Do you or any household member receive income from assets, including interest on checking or savings accounts; interest and
dividends from certificates of deposit(s), stocks, or bonds or income from rental property:? _______________
2.
Have you sold any real estate in the last two years? ____________
3.
Do you own any stocks or bonds? ___________ (List amount of stocks/bonds and Bank of Account Below)
________________________________________________________________________________________________________
__________________________________________________________________________
4.
Do you have a savings account or checking account?_______ if yes, give bank account numbers and amounts.
________________________________________________________________________________________________________
_________________________________________________________________________.
IV. SOURCES OF INCOME
1.
Does any family member receive any type of military pay/allotment (including Coast Guard, Natioal Guard, and Reserve Units)?
If yes, provide the family member name
_____________________________________________________________________________________
Amount $ _____________________________________________________________________________
Source of Pay/Allotment__________________________________________________________________
2.
Does any family member receive money to pay bills from someone outside of your household? If yes, provide family member
name ________________________________________________________________________
Amount of contribution ______________________________________________________________________
Name and address of party paying the bills: _____________________________________________________
_________________________________________________________________________________________
3.
Does
any
household
member
have
any
type
of
retirement
account
(company,
IRA,
_________________________________________________________________________________________
Keogh)?
4.
Does any family member have any inheritances, lottery winnings, or lump-sum payments from any other source?
________________________________________________________________________________________
5.
Do any household members have any life insurance policies? If yes, list the insurance company policy holder’s name and policy
number: ____________________________________________________________________
_________________________________________________________________________________________
6.
Have you received any child support payments in the past 12 months? ______________ If yes, list the amount and the name of
the person who you receive child support payments from: ________________________________________________________
7.
Do
you
receive
food
stamps?
______
If
yes,
provide
the
amount
you
receive
________________________________________________________________________________________.
V. BACKGROUND INFORMATION:
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monthly.
1. Do you own a car? ____________________________ Model/Year ______________________________
Tag No. _________________
Do you own a second car? ______________________ Model/Year ______________________________
Tag No. _____________
2.
Have you or any other adult member ever used any name(s) or Social Security number(s) other than the one you are currently
using? Yes/No ___________
If yes, explain: _____________________________________________________________________________
3.
Have you or any member lived in any assisted housing? Yes/No _____
If Yes, list where and when: __________________________________________________________________
_________________________________________________________________________________________
4.
Have you or anyone in your household ever been convicted of a Felony, Crime of Physical Violence, or a Drug-Related Crime?
Yes/No _________________ If yes, explain: ___________________________________________________
_________________________________________________________________________________________
5.
Have you ever committed any fraud in a Federally assistance housing program or been requested to repay money for knowingly
misrepresenting information for such housing programs? Yes/No _____
If yes, explain: _____________________________________________________________________________
_________________________________________________________________________________________
6. Have you or anyone in your household ever been convicted or arrested for a crime other than a traffic violation?
____________________________________________________________________________________________
7. Have you ever been evicted from public or assisted housing for any reason (including drug-related activities)?
1. Please list the monthly payments you make on the following:
Automobile ______________
Gasoline __________________
Furniture ____________________
Electricity _______________
Natural Gas ________________
Television ___________________
Cablevision ______________
Telephone _________________
Satellite _____________________
Cellphone _______________
Child Care _________________
Clothing _____________________
Other items not listed above:
_________________________________________________________________________________________
_________________________________________________________________________________________
VI. WORK HISTORY: Please list work history for all adult household members for last two jobs. Please start with most
recent jobs.
FAMILY MEMBER
EMPLOYER’S
NAME
FROMTO
TYPE OF
WORK PERFORMED
Please provide the family member(s) information for each of the following questions:
1.
Does any household member receive full-time or part-time earnings from any type of employment, including self-employment?
Yes [ ] No [ ]
If yes, provide name of employer and employer address and telephone
number._________________________________________________________________________________________________
__________________________________________________________________________
2.
Has anyone in your household started a new job or had an increase in earings? Yes [ ] No [ ] If yes, please answer the
following:

Is this a person with a disability? __________________________________________________________
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
Has the person been unemployed for one year or longer? _______________________________________

Is this person participating in any type of economic self-sufficiency program? _______________________

Has
this
person
received
TANF
benefits
in
the
past
six
months,
including
one-time
cash
payments?
_____________________________________________________________________________________
3.
Does any family member receive unemployment compensation, workers compensation, or severance pay?
Yes [ ] No [ ] If Yes, please provide the family member’s name:
_________________________________________________________________________________________
4.
Does any household member receive child support from a child support recovery unit? List household member information (child
receiving support for and person who is making the child support payment) and the amount of payment.
_________________________________________________________________________________________
_________________________________________________________________________________________
5.
Does any household member receive child support directly from an absent parent? If yes, provide the absent person who is
making the child support payments, amount of payment, and the name(s) of the children the support is for:
_________________________________________________________________________________________
_________________________________________________________________________________________
6.
Did any family member file a federal income tax return last year? If yes, who: __________________________
_________________________________________________________________________________________
7.
Does any household member receive alimony? If yes, who, and name of person paying alimony:
_________________________________________________________________________________________
8.
Has anyone in your household applied for any of the following: work, TANF, unemployment compensation, SS, SSI, pension or
disability benefits? ____________________________________________________________
_________________________________________________________________________________________
VII. REFERENCES (FRIENDS OR RELATIVES)
NAME
STREET
ADDRESS
CITY & STATE
ZIP
PHONE
RELATION
STATE LAW CONCERNING THE OBTAINING OF PUBLIC HOUSING BY FRAUDULENT MEANS ANY PERSON WHO OBTAINS
OR ATTEMPTS TO OBTAIN, OR WHO ESTABLISHES, OR ATTEMPTS TO ESTABLISH, ELIGIBILITY FOR, AND ANY PERSON
WHO KNOWINGLY OR INTENTIONALLY AIDS OR ABETS SUCH PERSON IN OBTAINING OR ATTEMPTING TO ESTABLISH
FOR, PUBLIC HOUSING OR A REDUCTION IN PUBLIC HOUSING RENTAL CHARGES, OR ANY RENT SUBSIDY, TO WHICH
SUCH PERSON WOULD NOT OTHERWISE BE ENTITLED, BY MEANS OF A FALSE STATEMENT, FAILURE TO DISCLOSE
INFORMATION, IMPERSONATION, OR OTHER FRAUDULENT SCHEME OR DEVICE, SHALL BE GUILTY OF A
MISDEAMEANOR AND UPON CONVICTION, SHALL BE PUNISHED FOR A MISDEAMEANOR.
I, _____________________________________________________, do hereby swear and attest that all of the information above
about me is true and correct. I also understand that I must report all changes in the income of any member of the household
as well as any changes in the household members to the Housing Authority in WRITING IMMEDIATELY.
_________________________________________________
Date: ____________________________
Signature of Head of Household
__________________________________________________ Date: ______________________________
Signature of Spouse or Other Adult
WARNING!!! TITLE 18, SECTION 1001 OF THE UNITED STATES CODE, STATES THAT A PERSON IS GUILTY OF A FELONY
FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OR AGENCY
OF THE UNITED STATES OF THE DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT. THE ABERDEEN HOUSING
AUTHORITY UTILIZES THE DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT’S UP-FRONT INCOME
VERIFICATION SYSTEM TO OBTAIN SS AND SSI BENEFITS, STATE WAGE INFORMATION, TANF BENEFITS, AND PRIVATE
SECTOR DATABASES TO VERIFY ALL FAMILY HOUSEHOLD WAGE/BENEFIT INFORMATION .
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USE SPACE BELOW FOR COMMENTS OR EXPLANATIONS:
_______________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________
PLEASE COMPLETE THE INFORMATION BELOW IN THE PRESENCE OF A NOTARY PUBLIC.
I, ________________________________________________, do hereby certify that I have no other income other than what I have listed on
the front of this form. I further certify that this includes the amount of income I expect to receive the next twelve (12) months. If I receive
additional income, I will report it to the Aberdeen Housing Authority within ten (10) days. I understand that failure to report additional
income could result in termination of my Dwelling Lease Agreement and may result in retroactive rental charges.
_______________________________________________________
Signature of Head of Household
Date: ______________________________________
_______________________________________________________
Signature of spouse or co-head (if applicable)
Date: ______________________________________
STATE OF MISSISSIPPI
COUNTY OF _____________________________
CERTIFICATION
This is to certify that _________________________________________________ personally appeared before me on this the ___________
Day of _________________________, 2______, and acknowledged that he/she signed the foregoing statement as a free and voluntary act.
_________________________________________________
Notary Public
MY COMMISSION EXPIRES: ________________________________________
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LOCAL PREFERENCE CERTIFICATION
P. O. BOX 69 . 910 MARTIN LUTHER KING STREET
ABERDEEN, MS 39730
PHONE: (662) 369-9460 . FAX: (662) 369-3366
APPLICANT NAME: ________________________________________________________________________
ADDRESS: _________________________________________________________________________________
CITY: ____________________________________________ STATE: _____________ ZIP: ______________
ALL STATEMENTS BELOW MUST BE CHECKED WITH EITHER TRUE OR FALSE WITH
REGARDS TO YOUR CURRENT SITUATION:
1.
WORKING FAMILY: In order to bring higher income families into public housing,
the PHA has established a preference for “working” families, where the head, spouse, co head, or
sole member is employed at least 20 hours per week. As required by HUD, families where the
head and spouse, or sole member is a person age 62 or older, or is a person with disabilities, will
also be given the benefit of the working preference [24 CFR 960.206(b)(2)].
A. My family has a head of household, spouse, co-head, or sole member that is
employed at a minimum of twenty (20) hours per week.
True ____________ False _____________
B. My family has a head of household, spouse, co-head, or sole member is a person age 62
years or older, or is a person with disabilities.
True ____________ False _____________
2. VETERAN PREFERENCE: My family has a head of household, spouse, co-head, or sole
member that is a person who is a veteran. A veteran is a person or a person who has served
in any branch of the armed forces of the United States of America.
True ____________ False _____________
3.
INVOLUNTARILY DISPLACED: Person or family that is involuntarily displaced
(within the last six months) by Government action, domestic physical violence or hate
crimes, unit inaccessibility, or whose dwelling has been extensively damaged or destroyed as
a result of a natural disaster or otherwise formally recognized pursuant to Federal disaster
relief laws or a person or family who has been displaced by any act of nature, such as
flooding, hurricane, tornado, earthquake, or lightning fires that results in the applicant’s
dwelling unit being uninhabitable.
A. Displaced by Government Action: I have been within the last six months or will be
displaced by an Agency of the United States or a local Governmental body in
connection with code nforcement or public improvement or development program.
True ____________ False _____________
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B. Displaced by Natural or Federal Disaster: My dwelling unit is uninhabitable because
of a Federally-declared or Natural disaster such a fire, flood, hurricane, etc.
True ____________ False _____________
C. Displaced for Domestic Physical Violence or Hate Crimes: I have vacated, within the
last six months, due to actual or threatened physical violence directed against me or
one or more members of my family by my spouse or another member of my
household; or I am living in the same unit with such an individual who engages in
such violence. My family or a member of my family has been or is being subjected to
actual or threatened physical violence or intimidation against my person or property
based on race, color, religion, sex, age, national origin, disability, or familial status.
True ____________ False _____________
D. Displacement due to Inaccessibility of a Unit: A member of my household has a
mobility or other impairment that makes it unable to use critial elements of my unit
and the owner is not legally obligated to make the necessary changes as a reasonable
accommodation to the disabled person.
True _____________ False _____________
E. Displacement because of HUD disposition: HUD is required by law to sell some of
the sites it owns, and my family is forced to move as a result of HUD’s sale of the site
I live in.
True ____________ False _____________
4.
LIVING IN SUBSTANDARD HOUSING: A person who lives in substandard housing.
This is housing that is dilapidated and does not provide safe and adequate shelter and its
condition endangers the health, safety, or well-being of my family; does not have operable
indoor plumbing; does not have electricity or adequate and safe electrical service; does not
have a safe and adequate source of heat; or does not have a kitchen.
True ____________ False _____________
NOTE: At the time of application, initial determinations of an applicant’s entitlement to a
local preference may be made on the basis of the applicant’s certification of their
qualification for that preference. Before selection is made, this qualification will be verified
before selection for admission.
CERTIFICATION OF THE APPLICANT APPLYING FOR THE LOCAL PREFERENCE:
I DO HEREBY CERTIFY THAT, AS INDICATED, I AM ENTITLED TO A LOCAL PREFERENCE, AND
HEREBY AM APPLYING FOR SAME.
I UNDERSTAND THAT PRIOR TO RECEIVING THE
PREFERENCE, I WILL BE REQUIRED TO FURNISH DOCUMENTED PROOF AS REQUESTED BY
THE HOUSING AUTHORITY.
DATED THIS THE ________________ DAY OF _____________________, ________________.
________________________________________________________
Signature of Applicant Head of Household
_________________________________________________________
Signature of Spouse (if applicable)
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CERTIFICATION OF APPLICANT WHO DOES NOT FEEL THEY ARE ELIGIBLE FOR A LOCAL
PREFERENCE.
I HAVE ANSWERED ALL OF THE QUESTIONS BUT DO NOT FEEL THAT I QUALIFY FOR ANY
LOCAL PREFERENCE. I REQUEST THAT YOU KEEP THE APPLICATION ON FILE FOR HOUSING
ASSISTANCE.
DATED THIS THE ________________ DAY OF _____________________, ________________.
________________________________________________________
Signature of Applicant Head of Household
_________________________________________________________
Signature of Spouse (if applicable)
FOR OFFICE USE ONLY
(
) QUALIFIES FOR A LOCAL PREFERENCE
(
) DOES NOT QUALIFY FOR A LOCAL PREFERENCE.
REVIEWED BY ____________________________________________ DATE: __________________________
AHA Representative
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GENERAL INFORMATION AND CONTACT SHEET
APPLICANT NAME: _________________________________________________________
ADDRESS: __________________________________________________________________
CITY: _____________________________ STATE: _____________ ZIP: ______________
PHONE: _____________________________________________________________________
List the Names, address, and telephone number of two relatives or friends who generally
know how to contact you.
NAME: _____________________________________________________________________
ADDRESS: __________________________________________________________________
CITY: _____________________________ STATE: _____________ ZIP: ______________
PHONE: _____________________________________________________________________
NAME: _____________________________________________________________________
ADDRESS: __________________________________________________________________
CITY: _____________________________ STATE: _____________ ZIP: ______________
PHONE: _____________________________________________________________________
Please place an “X” in the spaces below for the following questions:
1. Does anyone live with you now who is not listed on the application for admission form?
______ Yes
______ No
2. Do you plan to have anyone living with you in the future who is not already listed?
______ Yes
______ No
3. Is the head, spouse, co-head, or sole member of this household handicapped or disabled?
______ Yes
______ No
4. Please identify any special housing needs required as a result of the handicap:
______________________________________________________________________________
5. How many people live in your home now? _______________
6. How many bedrooms do you presently have in your home? ________________
7. Are you being evicted?
______ Yes
______ No
8. Are you being displaced from your present home?
______ Yes
______ No
9. What is your current rent? __________________
10. What is your monthly cost of all utilities, excluding telephone? ___________________
11. What is the condition of your current housing?
Standard ________ Unsafe _________ Unhealthy _________ No indoor plumbing
______________
No Kitchen facilities __________ Currently without housing ___________
APPLICATION PACKET
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12. Who is your current landlord (include address and telephone)?
______________________________________________________________________________
13. Does any member of your household expect to work for any period during the next 12
months?
______ Yes
______ No
14. Does any member of your household work for someone who pays them in cash?
______ Yes
______ No
15. Is any member of your household on leave of absence from work due to layoff, medical,
maternity, or military leave?
______ Yes
______ No
16. Does any member of your household now receive, or expect to receive, unemployment
benefits?
______ Yes
______ No
17. Is any member of your household entitled to child support that he/she is not receiving?
______ Yes
______ No
18. Is any member of your household entitled to alimony payments that he/she is not
receiving?
______ Yes
______ No
19. Does any member of your household receive, or expect to receive, Welfare?
______ Yes
______ No
20. Does any member of your household receive, or expect to receive, Social Security?
______ Yes
______ No
21. Does any member of your household receive, or expect to receive, income from a
pension or annuity?
______ Yes
______ No
22. Does any member of your household receive cash contributions from individuals not
living in the unit or from an agency?
______ Yes
______ No
23. Does any member of your household receive income from assets including interest on
checking or savings accounts, interest and dividends from certificates of deposits, stock or
bonds, income from the rental of property?
______ Yes
______ No
24. Does any member of your household receive, or expect to receive, an earned income tax
credit?
______ Yes
APPLICATION PACKET
______ No
16
AUTHORIZATION FOR RELEASE OF BACKGROUND
AND CRIMINAL RECORD INFORMATION
In conducting a background search of any applicant or resident, the Aberdeen Housing Authority
will keep any and all background and criminal records in strict confidence and will not misuse or
improperly disseminate the information. Criminal records which are used as a basis for denial
for housing assistance or eviction in the case of a current Aberdeen Housing Authority resident
are confidential and will not be disclosed to any person other than for official use or for use in
court proceedings.
Date: __________________________________________________________________
Resident Name: __________________________________________________________
Resident Nickname (if any): ________________________________________________
Current Address: ________________________________________________________
Previous Address: ________________________________________________________
Date of Birth: __________________________
Weight: ______________
Height: _______________________
Race: _________________ Sex: ___________________
Hair Color: _________________ Social Security Number: _____________________
I do hereby understand and authorize the Aberdeen Housing Authority to conduct a search
of by background. I hereby authorize any City, County, State, or Federal Agency,
Department or Bureau, to release any information in their files to the Aberdeen Housing
Authority. I understand and realize that the information so released may prove
unfavorable to me. I agree to submit to fingerprinting to be forwarded to the FBI if
required by the Aberdeen Housing Authority. I agree to hold any source of information
blameless for any error in reporting this information. I release all persons whomever from
any liability arising out of or resulting from the release of this information.
Signature: _______________________________Date: __________________________
Date of Birth: ____________
APPLICATION PACKET
Social Security Number: _____________________
17
P. O. BOX 69 910 MARTIN LUTHER KING STREET
ABERDEEN, MISSISSIPPI 39730
(662) 369-9460 . FAX (662) 369-3366
EMAIL: [email protected]
To Whom It May Concern:
The person named below has applied for, or is occupying subsidized housing which is
managed by the Aberdeen Housing Authority. In order to establish his/her eligibility, we
are requesting information regarding any legal activities (including illegal drug-related
criminal activities) or disturbances. Your cooperation in supplying the necessary
information that is being requested by the Aberdeen Housing Authority will be
appreciated.
Sincerely,
AHA Management
-----------------------------------------------------------------------------------------------------------Name: _________________________________________________________________
Address: _______________________________________________________________
Social Security Number: ___________________________________________________
Date of Birth: __________________________
Race/Sex: _____________________
Last Known Address: _____________________________________________________
-----------------------------------------------------------------------------------------------------------Arrest Record: ___________________________________________________________
________________________________________________________________________
________________________________________________________________________
Disturbance Calls: ________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Signature and Title
Date: __________________________________________________________________
APPLICATION PACKET
18
TANF, FOOD STAMPS, AND CHILD SUPPORT VERIFICATION
PLEASE VERIFY FOOD STAMPS
PLEASE VERIFY CHILD SUPPORT
PLEASE VERIFY TANF
The Aberdeen Housing Authority is required to verify the income of all applicants and
residents in our low-income pubic housing program. We are requesting your cooperation
in supplying the requested information as listed below. Thank you for your support in this
matter.
Sincerely,
AHA Management
Date: ______________________________________
Phone: 662-369-9460
-----------------------------------------------------------------------------------------------------------Applicant/Resident Name:_________________________________________________
Address: _______________________________________________________________
Social Security Number: __________________________________________________
I do hereby give the Department of Human Services permission to furnish the Aberdeen
Housing Authority with the information requested.
______________________________________
Applicant/Resident Signature
Date__________________________
Section A: (Department of Human Service, Division of Economic Assistance)
Benefits: [ ] TANF $__________________Start Date: _____________________
No. of Adults: __________________
No. of Children: _______________
[ ] Food Stamps: $____________Start Date: ____________________
No. of Adults: __________________
No. of Children: _______________
Supportive Services: [ ] Child Care
[ ] Transportation [ ] TCC [ ] TT
[ ] Bonus Payments
Employed: [ ] Yes [ ] No. If yes, employer: ____________________________
Education (last grade completed): _____________________________________
Work Program Status: [ ] Mandatory
[ ] Exempt
Reason: __________________________________________________________
Work Activity Assignment: __________________________________________
Start Date: ________________________ End Date: ____________________
Sanction Level: [ ] 2 mos. [ ] 6 mos. [ ] 12 mos. [ ] Permanently Disqualified
Start Date: ________________________ End Date: ____________________
Reason: __________________________________________________________
COMMENTS: ___________________________________________________________
________________________________________________________________________
________________________________________________________________________
____________________________________
Date: ________________________
Signature
____________________________________
Phone: _______________________
Title
-----------------------------------------------------------------------------------------------------------Section B: (Department of Human Services, Division of Child Support Enforcement)
APPLICATION PACKET
19
Aid to Dependent Children [ ] Yes [ ] No
Amount per month: $___________________
Child Support: [ ] Yes [ ] No
Effective Date: ________________________
If yes, please attach payment history (prior 12 months), if provided.
COMMENTS: ___________________________________________________________
________________________________________________________________________
________________________________________________________________________
Do you have information of any income from other sources for the person listed above, or
anyone living at this address: [ ] Yes [ ] No If yes, please provide amount per month:
$___________________ beginning date. Ending date: ___________________
____________________________________
Signature
____________________________________
Title
APPLICATION PACKET
Date: ________________________
Phone: _______________________
20
REQUEST FOR VERIFICATION OF EMPLOYMENT
Date:
____________________________________
____________________________________
____________________________________
RE: Name: _____________________________________________________________
Address: ___________________________________________________________
Social Security No: ___________________________________________________
Dear Employer:
The Department of Housing and Urban Development’s regulation requires the Aberdeen
Housing Authority to verify employment income of household/family member(s) living in or
applying for public housing rental assistance.
We would greatly appreciate your prompt return of this letter to the Authority so we can verify
this family’s annual income. Please fax or mail this form to: The Aberdeen Housing Authority,
P. O. Box 69, Aberdeen, MS 39730, call 662-369-9460, or fax 662-369-3366. DO NOT SEND
THIS INFORMATION BY THE EMPLOYEE.
____________________________________
AHA Representative
Date: ________________________
I hereby request that you furnish information to the Aberdeen Housing Authority
regarding my employment. I understand that this information will be kept in strict
confidence, and will be used only for the program purposes.
____________________________________
Date: ________________________
Signature of Applicant/Resident
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Employment Information:
Present Position: _________________________________________________________
Date Hired: ___________________________
Date Terminated: ______________
Probability of Continued Employment: YES [ ] NO [ ]. If No, please explain below:
________________________________________________________________________
Payroll Information:
Current Base Pay: $________________
Above amount is per [
[
[
[
] Hour
] Week
] Bi-Weekly
] Other: Explain:
Hours Per Week: _______________
[ ]
Twice Monthly
[ ]
Month
[ ]
Annually
____________________________________
If applicable, will be employee be able to file for unemployment benefits? [ ] Yes [ ] No
Earnings to Date:
Current Year: $________________
APPLICATION PACKET
As of (Date): ________________________
21
Previous Year:$________________
Date Ending: ________________________
Overtime or Bonus Pay:
Overtime Hours per Week: _________________
Is likely to Continue? [ ] Yes [ ] No
Bonus Pay: $__________________ Explain: __________________________________
Vacation Pay: [ ] YES [ ] NO. If yes, please provide the following information:
Number of vacation days per year: ______________
Anticipated Pay Raise:
Amount per Pay Period: $___________________ Effective Date: _________________
Remarks: (If paid hourly, please indicate the average hours worked each week. Indicate if
conditions such as weather, season, etc., affect the number of hours worked)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
-----------------------------------------------------------------------------------------------------------Certification:
This form should be completed and signed by a bona fide representative of the employer such as
a bookkeeper or accountant. IN NO EVENT SHOULD THE EMPLOYEE COMPLETE THIS
FORM. Federal statues provide severe penalties for any fraud, intentional misrepresentation,
or criminal intent.
__________________________________________
Signature
Date: __________________
_________________________________________
Title
Phone: _________________
APPLICATION PACKET
22
Aberdeen Housing Authority
P. O. Box 69
Aberdeen, MS 39730-6609
Telephone: 662-369-9460
Landlord Reference Form
Date:
____________________________________
____________________________________
____________________________________
RE: Name: _____________________________________________________________
Address: ___________________________________________________________
Dear Sir or Madam:
Please furnish the Aberdeen Housing Authority with the following information on the above
referenced applicant who has submitted an application for housing assistance with this Authority.
We would greatly appreciate your prompt return of this letter. A self-addressed, stamped
envelope is enclosed for your convenience. The person referenced above has authorized your
release of their information to the Aberdeen Housing Authority. If you have any questions,
please contact the undersigned at (662) 369-9460.
Sincerely,
AHA Representative
I do hereby give the above referenced individual permission to furnish the Aberdeen
Housing Authority with the information requested.
______________________________________
Date__________________________
Applicant/Resident Signature
-----------------------------------------------------------------------------------------------------------1. Rental History: From _____________________
To_____________________
Monthly Rent Amount $_________________
 Good (paid on or before due date)
__________
 Fair (paid within the month rent due)
__________
 Poor (late payment of rental)
__________
 Times late during 12-month period
__________
2. Housekeeping Standards:
 Good
 Fair
 Poor
__________
__________
__________
3. Maintenance Requests:
 Routine Calls
__________
 Excessive Calls
__________
 Evidence of Property Abuse
__________
o Explanation of abuse: ___________________________________
o _______________________________________________________
4. Relationship With Neighbors:
 Good
 Fair
 Poor
APPLICATION PACKET
__________
__________
__________
23
5. Relationship With Management:
 Good
 Fair
 Poor
__________
__________
__________
6. Social Behavior:
 Good
 Fair
 Poor
__________
__________
__________
Would you rent to this person again? [ ] Yes
[ ] No
Please provide an explanation for any question(s) you have marked “poor:”
________________________________________________________________________
_______________________________________________________________________
7. Other Comments:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
------------------------------------------------------------------------------------------------------------
_________________________________________ Date: ________________________
Signature
Telephone: ___________________________________________
APPLICATION PACKET
24
Aberdeen Housing Authority
P. O. Box 69
Aberdeen, MS 39730-6609
Telephone: 662-369-9460
REQUIRED RESIDENT BRIEFING INFORMATION
1. RENT: Rent is due on or before the first day of each calendar month and is late if not paid
by the tenth (10th) of each month.
2. LATE CHARGE: A fifteen dollar ($30.00) late fee will be charged to each resident whose
rent is reeived by the Housing Authority office after the tenth (10th) day of each calendar month.
3. FINANCIAL HARDSHIP: Management should be notified immediately of financial
hardships affecting the resident’s ability to pay rent or utilities.
4. MAINTENANCE: Resident must keep the premises assigned to him/her in a clean, sanitary
safe, and good condition. Housekeeping inspections will be performed every three (3) months.
5. DAMAGE: Resident is required to pay for damages and repairs to the apartment as set forth
in the signed and executed Dwelling Lease Agreement.
6. REPAIRS: Resident must report all requests for repairs directly to the Administrative
Office. Someone from the Maintenance Department will enter your apartment to perform repairs
unless a scheduled time has been agreed upon between the Resident and Management.
7. REPAIR COSTS: All maintenance charges will be in accordance with the current Standard
Repair Charge List.
8. DISTURBANCE AND DESTRUCTION: Disturbance of neighbors or damaging Housing
Authority property by family members or guests will not be condoned. Batteries must remain in
smoke detectors at all times. There will be a charge issued to you for tampering, damaging,
and/or removing smoke detectors.
9. ASSIGNMENT OF UNIT: Resident understands that if he/she is assigned to an apartment
larger than that authorized by the Housing Authority policies, he/she may be required to move to
a smaller unit at a future date. By signing below, resident is agreeing to move if requested to
move by the Housing Authority.
10. ASSIGNMENT OF ACCESSIBLE OR ADAPTABLE UNITS: Before offering a vacant
handicapped accessible unit to a non-disabled applicant, the AHA will offer such units as
follows: (1) first to a current resident within the AHA’s properties having a disability that
requires the special features of the unit, and (2) to an eligible, qualified applicant on the waiting
list having a disability that requires the special features of the accessible/adaptable dwelling unit.
If a non-disabled resident is occupying an accessible/adaptable dwelling unit, the AHA will
require the applicant to agree to move to an available non-accessible unit within thirty (30) days
or whenever an applicant/resident requires the accessible/adaptable dwelling unit.
11. Any changes in income, family composition, and health status must be reported in writing
within ten (10) days of the change.
12. Annual re-examinations are done beginning the month of January to be effective April first
of each calendar year. Resident agrees to furnish the necessary information to complete
reexaminations.
13. Resident understands that it is his/her responsibility to get their own renter’s insurance for
their personal contents.
By signing below, resident acknowledges that they have been briefed on the above terms.
________________________________________
APPLICATION PACKET
25
Date:_______________________________

Application Packet - Aberdeen, Mississippi Housing Authority

Transcription

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