Personal Declaration of Eligiblity

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Coleen Alexander
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To be completed by Housing Authority of Interview / / Initial Annual Interim Move Name of Tenant: Interviewed by: _ I. Contact Information Name: Address: Email Address: II.

1 To be completed by Housing Authority of Interview / / Initial Annual Interim Move Name of Tenant: Interviewed by: _ I. Contact Information Name: Address: Address: II. Marital Status Marital Status: Housing Choice Voucher Department Personal Declaration of Eligiblity Head of Household Information Home Phone: Cell Phone: Work Phone: Single Married Divorced Spouse's name: Address III. Next of Kin/ Emergency Contact Name: Address: City: State: Zip: Phone: Relationship: IV. Language Primary Language: Translation Needed? This information is being requested to comply with Equal opportunity requirements and will not affect your housing assistance Household Information I. Starting with yourself, list all persons who will be living in your home of Disability Relationship to Head Name Birth Yes/No of Household 1 Head Social Security # II. Changes to Household Composition 1. Has anyone left the household since your last recertification? Yes 2. Has anyone been added to your household? 3. Please list any household members that need to be added or deleted Name Adding or Deleting Reason 4. Is there any member of the household who is temporarily absent from the home? (Include any children currently in foster care) Who? Why?_ III. Education 1. Is any household member, 18 years of age or older, attending school? Yes Name Name of School Grade Page 1 of Harden Blvd., Suite 140, Lakeland, FL Status (circle one) full time/ part time full time/ part time

2 I. Employment Income Income 1. Are you or any household member currently employed? Yes Name of Employer Address Phone Fax Hours per week: Paid: $ Daily Weekly Bi weekly Monthly Name of Employer Address Phone Fax Hours per week: Paid: $ Daily Weekly Bi weekly Monthly You must provide copies of last 8 weeks consecutive pay stubs. Or, provide a letter from your employer stating: date employment began, rate of pay, and # of hours worked per week 2. Has your place of employment changed since your last recertification? If yes, name of previous employer: Address: Phone: Fax: II. Other Income 1. Are there any other income sources received by ANY member of your household? If yes, check the source of income below Unemployment Pension/Annuity Child Support VA Benefits Self Employment Workman's Comp Alimony Education Grants SS/ SSD/ SSI TANF Food Stamps On the chart below list the gross amount for all of the income sources checked above Household Member Source of Income Amount How often? III. Contributions/Gifts 1. Does anyone outside of your household pay any of your bills or give you or any member of your household money? If yes, how much is given? Who gives it? _ How often is it given? IV. Business 1. Are you an owner or co owner of a business? Name of the business (Provide copy of prior year's Schedule C) V. Earned Income Disallowance SECTION 8 ONLY (Only eligible if already on program) 1. Are there any disabled adults, 18 years of age or older, in your household that are currently employed? If you answered "No", skip to Assets 2. Was the disabled household member previously unemployed for one or more years prior to becoming employed? 3. Did the disabled household member's income increase during participation in any self sufficiency or other job training program? 4. Did the disabled household member 's income increase as a result of new employment or increased earnings during or within 6 months after receiving TANF benefits? PUBLIC HOUSING ONLY 1. Are there any household members, 18 years of age or older, that are currently working and who were previously unemployed for one or more years prior to employment? If yes, please complete the Earned Income Disallowance form Page 2 of 4

3 I. List all assets held by all household members Type of Asset Do you have? Household Member Value Bank/ Institution Checking Account Savings Account Money Market Life Insurance Annuities/CDs IRA/Retirement Trust Stocks/Bonds Provide copies of most recent statements for all assets. Last 6 months for checking account(s) II. Disposal of Property 1. Have you disposed of, sold, or given away any assets for less than the Fair Market Value in the past two (2) years? If yes, please complete the following: 1) Type of asset: 3) Amount received: $ 2) of disposal: 4) Market value: $_ III. Real Estate 1. Do you own, or are you in the process of purchasing a house, mobile home, or any other form of real estate? Address of property Is this a rental property? I. Medical Expenses 1. Is head or spouse 62 years of age or older? 2. Is head or spouse disabled? If you answered yes to either of the above questions, please answer the following: If you answered No, please skip to next section 3. Are there any ongoing, recurring out of pocket expenses associated with the care of the disabled individual? Type of Expense Name of Provider Address Insurance Premium Rx/ Medicaons Doctor/Dental/Hospital Insurance Premium Rx/ Medicaons Doctor/Dental/Hospital Insurance Premium Rx/ Medicaons Doctor/Dental/Hospital Assets Deductions Phone/Fax Provide receipts for non covered expenses, a pharmacy print out showing your payment, a twelve (12) month account statement from provider, or cancelled checks showing payment II. Disability Assistance Expense Does your family have un reimbursed medical expenses to cover a care attendant or an auxillary apparatus for a disabled houshold member to enable any household member to be employed? If yes, please detail the expense below Type of expense Amount III. Childcare Expenses 1. Are any children in the household under the age of 13? If yes, complete 1, 2, and 3 1. Are you working? 2. Are you currently participating in a program that is assisting you with finding employment? If yes, provide a letter from the program Page 3 of 4

4 3. Are you a full time student? Yes If you answered yes to 1, 2, or 3, and have child care expenses, please complete the following Name of child care provider: Address: Phone _ Out of Pocket Cost: $ Paid: Weekly Bi weekly Monthly Name of child care provider: Address: Phone Out of Pocket Cost: $ Paid: Weekly Bi weekly Monthly Criminal History 1. Has anyone in your household, including adults and minors, ever engaged in, been cited, arrested, indicted, convicted, placed on probation, or had adjudication withheld, or had charges dropped, or nolle prossed in connection with drug related criminal activity or violent criminal activity or any felony charge? If yes, who? When? What was the outcome? In what city and state? 2. Has anyone in your household, adults and minors, ever been placed on parole or probation? If yes, who? when? Is any member still on parole or probation? If yes, provide the parole/probation officer's name and phone number By my signature below, I do hereby swear and attest that all of the information reported on this form about me and my household is true and correct. I also understand that all changes in household composition or income must be reported to the Housing Authority in writing within 10 days of the change. WARNING! Title 18, Section 1001 of the United States Code states that a person is guilty of a felony for knowingly making false or fraudulent statements to any department or agency of the United States or the Department of Housing and Urban Development (HUD). Signature of Head of Household Signature of Spouse or Other Adult Signature of Other Adult Signature of Other Adult To be completed by Housing Authority I certify that I have reviewed the information on this form for completeness and accuracy and am acting in accordance with LHA policy and HUD regulations. Housing Advisor Signature Page 4 of 4

5 LAKELAND HOUSING AUTHORITY 1818 Harden Blvd., Suite 140 Lakeland, FL Obligations of the Housing Choice Voucher Participant Supplying Required Information The family must supply any information that the Lakeland Housing Authority or HUD determines is necessary in the administration of the program, including submission of required evidence of citizenship or eligible immigration status. Information includes any requested certification, release or other documentation. The family must supply any information requested by the Lakeland Housing Authority or HUD for use in a regularly scheduled reexamination or interim reexamination of family income and composition in accordance with HUD requirements. The family must disclose and verify Social Security Numbers and must sign and submit consent forms for obtaining information. All information supplied by the family must be true and complete. Housing Quality Standards (HQS) Responsibilities of the Family The family is responsible for any HQS breach caused by the family or its guests. The family must keep and maintain utilities, for which the tenant is responsible, on in the assisted unit at all times. The family must provide and maintain any appliance(s), which are to be provided by the tenant under the lease agreement. The family must allow the Lakeland Housing Authority or authorized contractor to inspect the assisted unit at reasonable times and after at least 2 calendar days notice according to state law. Additional Responsibilities of the Family The family must not commit any serious or repeated violations of the lease agreement. The family must notify the Lakeland Housing Authority and the owner before the family moves out of the unit or terminates the lease by a notice to the owner. The family must promptly give the Lakeland Housing Authority a copy of any owner eviction notice it receives. The family must use the assisted unit for a residence by the family. The unit must be the family s only residence. The Lakeland Housing Authority must approve the composition of the assisted family residing in the within 10 business days of the birth, adoption or court awarded custody of a child. The family must request approval from the Lakeland Housing Authority to add any other family member as an occupant of the unit. No other person (i.e., no one but members of the assisted family) may reside in the unit (except for a foster child/foster adult or live in aide. The family must notify the Lakeland Housing Authority within 10 business days if any family member no longer resides in the unit. Members of the household may engage in legal profit making activities in the unit, but only if such activities are incidental to primary use of the unit for residence by members of the family. Any business uses of the unit must comply with the lease, zoning requirements and the affected household member must obtain all appropriate licenses. The family must not sublease or let the unit. The family must not assign the lease or transfer the unit. The family must supply any information or certification requested by the Lakeland Housing Authority to verify that the family is living in the unit, or relating to family absence from the unit, including any Lakeland Housing Authority requested information or certification on the purposes of family absences. The family must cooperate with the Lakeland Housing Authority for this purpose. The family must promptly notify the Lakeland Housing Authority of its absence from the unit. The family may not own or have any interest in the unit (except for owners of manufactured housing renting the manufactured home space or people using a housing choice voucher to purchase a home). The members of the family must not commit fraud, bribery, or any other corrupt or criminal act in connection with the program. The members of the household may not engage in drug related criminal activity or other violent criminal activity or other criminal activity that threatens the health safety or right to peaceful enjoyment of other residents and persons residing in the immediate vicinity of the premises. The assisted family, or members of the family, may not receive Section 8 tenant based assistance while receiving another housing subsidy, for the same unit or for a different unit, under any duplicative (as determined by HUD or in accordance with HUD requirements) Federal, State or local housing assistance program. This provision does not exclude units receiving Low Income Tax Credits. The members of the household must not abuse alcohol and/or drugs in a way that threatens the health, safety or right to peaceful enjoyment of other residents and/or persons residing in the immediate vicinity of the premises. I hereby certify that I have read and understand the above family responsibilities and obligations as a HCV participant. I further understand that if I fail to comply with any of these obligations, I may be terminated from the Housing Choice Voucher program: Head of Household Signature Co head/spouse or Adult over 18 years old

6 LAKELAND HOUSING AUTHORITY 1818 Harden Blvd., Suite 140 Lakeland, FL Supporting Documents Definitions Income Definitions Employment: The full amount, before any payroll deductions, of wages and salaries, overtime pay, commissions, fees, tips and bonuses, and other compensation for personal services. Self Employment: The net income from the operation of a business or profession. Expenditures for business expansion or amortization of capital indebtedness are not used as deductions in determining net income. An allowance for depreciation of assets used in a business or profession may be deducted, based on straight line depreciation, as provided in Internal Revenue Service regulations. Any withdrawal of cash or assets from the operation of a business or profession is included in income, except to the extent the withdrawal is reimbursement of cash or assets invested in the operation by the family. Unemployment, Disability or Worker s Compensation: Payments in lieu of earnings, such as unemployment and disability compensation, worker's compensation and severance pay. Social Security/SSI Benefits: The full amount of periodic amounts received from Social Security, annuities, insurance policies, retirement funds, pensions, disability or death benefits, and other similar types of periodic receipts, including a lump sum amount or prospective monthly amounts for the delayed start of a periodic amount. Alimony/Child Support, Monetary Contributions or Gifts: Periodic and determinable allowances, such as alimony and child support payments, and regular contributions or gifts received from organizations or from persons not residing in the dwelling. Welfare (Public Assistance): Welfare assistance payments made under the Temporary Assistance for Needy Families (TANF) program are included in annual income. Allowance Definitions Child Care: 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. The amount deducted shall reflect reasonable charges for child care. In the case of childcare necessary to permit employment, the amount deducted shall not exceed the amount of employment income that is included in annual income. Dependent: A member of the family (except foster children and foster adults) other than the family head or spouse, who is under 18 years of age, or is a person with a disability, or is a full time student. Disability Assistance Expense: Reasonable expenses that are anticipated, during the period for which annual income is computed, for attendant care and auxiliary apparatus for a disabled family member and that are necessary to enable a family member (including the disabled member) to be employed, provided that the expenses are neither paid to a member of the family nor reimbursed by an outside source. Full Time Student: A person who is attending school or vocational training on a full time basis as defined by the institution. Medical Expenses: Medical expenses, including medical insurance premiums that are anticipated during the period for which annual income is computed, and that are not covered by insurance. Asset Definitions Interest, dividends, and other net income of any kind from real or personal property. Expenditures for amortization of capital indebtedness are not used as deductions in determining net income. An allowance for depreciation of assets used in a business or profession may be deducted, based on straight line depreciation, as provided in Internal Revenue Service regulations. Any withdrawal of cash or assets from an investment is included in income, except to the extent the withdrawal is reimbursement of cash or assets invested by the family. Where the family has net family assets in excess of $5,000, annual income includes the greater of the actual income derived from all net family assets or a percentage of the value of such assets based on the current passbook savings rate, as determined by HUD. Income that could have been derived from assets worth more than $1000 that were disposed of for less than fair market value within the past two years will be counted as income. Examples of Assets: Checking and Savings accounts, Christmas Club accounts, Certificates of Deposit, IRA s, Stocks, Bonds, Trusts, and other Investment accounts. Certification of Asset Disposition: Please read each statement and check the statement that is true and correct concerning your household: I hereby certify that I HAVE NOT sold, or given away items worth more than $1, in the past two (2) years. I hereby certify that I HAVE sold, or given away items worth more than $1, in the past two (2) years: Fair Market Value of Property: $ (Please provide supporting documentation) Amount Received: $ I hereby certify that I have read and understand the above income, asset, and allowance definitions. I further certify to the certification of asset disposition and have properly reported all income, assets, and allowance information on my annual recertification application. Head of Household Signature Co head/spouse or Adult over 18 years old

405 SW 6 th St Redmond, OR Phone: Fax: SELF DECLARATION FORM

405 SW 6 th St Redmond, OR Phone: Fax: SELF DECLARATION FORM 405 SW 6 th St Redmond, OR 97756 Phone: 541-923-1018 Fax: 541-923-6441 SELF DECLARATION FORM Instructions for completing this form: Complete this form IN INK. Complete all blanks. All adult members in