Winnebago County Housing Authority 3617 Delaware Street Rockford, IL Phone: (815) Fax: (815)

Transcription

1 Winnebago County Housing Authority 3617 Delaware Street Rockford, IL Phone: (815) Fax: (815) Winnebago County Rental Housing Support Program efficiency-3 bedroom units, which applicants are assigned to through Winnebago County Housing Authority (WCHA), which are owned by private landlords with State of Illinois rental assistance through WCHA. Thank you for applying for the Rental Housing Support Program. For Questions about the program or your application you may contact Jessica Vanegas, Project Manager (815) ext. 114 All changes must be made in writing and submitted to the Winnebago County Housing Authority within 10 business days of the change including, but not limited to; mailing address, changes in preferences, etc. **Please be sure to write clearly on your application. ** (Please keep this page for your records)

2 RENTAL HOUSING SUPPORT PROGRAM APPLICATION Current Mailing Address: City: State: Zip Code: Telephone Number: Please list all household members that would be residing with you in your assisted unit, starting with the head of household. Legal Name Relation to Head head Sex of Birth Social Security Number Marital Status (single, married, divorced, widow, separated)

3 FOR HUD STATISTICAL PURPOSES ONLY: PLEASE IDENTIFY YOUR RACE AND ETHNICITY BY CHECKING A BOX IN EACH OF THE TWO CATEGOREIES BELOW: ETHNICITY: (please mark the appropriate box) Hispanic or Latino Non-Hispanic or Latino RACE: (please mark the appropriate boxes) White Black/African American American Indian/Alaska Native Asian Native Hawaiian/Other Pacific Islander In order to receive assistance, a family member must be a U.S. Citizen or have eligible immigrant status. Eligible immigrants are persons who are in one of six categories as specified by HUD. YES No Are you or any member of your household a Citizen of the United States? PLEASE NOTE: The following questions will be used to determine your preliminary preference point determination. Preference points are initially assigned based on this application and the Winnebago County Housing Authority will require independent verification of the factors which qualify you for each preference prior to providing housing assistance. These points may affect your placement on the waiting list. Have you resided in Winnebago County for the past immediate and consecutive 90 days? Are you a veteran, or the surviving spouse of a veteran? Are you or your spouse employed 20 hours per week? Do you or your spouse meet the HUD/Social Security definition of disability? Are your or your spouse aged 62 or older? Have you been terminated from a Housing Choice Voucher (Section 8) Program due to insufficient program funding within the last 5 years? YES No Are you a victim of the Violence Against Women s Act of 2013? YES No YES No YES No Have you been involuntarily displaced due to a Federally Declared Disaster? Were you in the custody of the child welfare system on or before your 18 th birthday and have not yet reached the age of 24? Are you a nursing home resident who has resided in a state-licensed nursing home for the immediate and consecutive past ninety calendar days and have been determined to be eligible for discharge?

4 Total Income Received By All Family Members Please check Yes or No for all of the following sources of income received by ALL household members. Any line you choose yes, please list which household member, amount and rate and name of provider. Type of income Wages, Employment, Tips, Commission (job) Self-Employment Social Security Or SSI (Any/All Household members) Disability Payments (other than SS or SSI) Workers Compensation Unemployment Pensions, Annuities, Retirement Funds Financial Assistance to attend school Death Benefits Lump Sum Payment TANF (cash assistance) Food Stamps (SNAP) Alimony Child Support Insurance Policies Regular contributions or gifts from anyone Interest, dividends or other income from property Other Income Not Listed Lump Sum Payment Name of Household member Amount and Rate Name of Provider Assets and Banking Information (FOR ALL HOUSEHOLD MEMBERS) **List any/all accounts, including accounts with a zero balance** Assets examples: Checking/Savings/Christmas Club account/child s account/equity in real estate/savings Bonds/Credit Union shares, etc. Type of Asset Please Check Provider/Bank Name/Address Real Estate Stocks/Bonds Company Retirement or Pension Insurance Settlement Checking Account Savings Account Certificate of Deposit (CD) Trusts Other

5 Authorizations, Representatives, and Certifications I/We, understand that any misrepresentations of information or failure to disclose information requested on this application may disqualify me from consideration or admission or participation, and are grounds for termination of assistance. I/We have given true and correct information. Written answers by staff accurately reflect my/our oral responses. WARNING! Title 18, Section 1001 of the U.S. code, states that a person who knowingly and willingly makes false or fraudulent statements to any Department of Agency of the U.S. or the Department of Housing and Urban Development is guilty of a felony. NOTICE: Any attempts obtain any rent subsidy or rent reduction by false information, impersonation, failure to disclose or other fraud, and any act of assistance to such attempt is a crime. Head of Household Signature Spouse or Other Adult Signature Other Adult Signature Other Adult Signature

6 Winnebago County Housing Authority 3617 Delaware St. Rockford, IL I/We authorize Winnebago County Housing Authority/Westport Village Apartments to do a complete investigation of my background. A complete investigation may include any or all of the following: Credit Report, Criminal Record, Rental History References, and Personal Interview with any references. My/Our signature(s) below authorizes all above listed organizations to release rental, job history (including salary) and criminal record information. Head of Household Signature Spouse/Other Adult Signature Other Adult Signature

7 WINNEBAGO COUNTY HOUSING AUTHORITY 3617 Delaware Street Rockford, IL Phone: (815) Fax: (815) Have you ever received Housing Choice Voucher (Section 8) Assistance through any other Housing Authority? YES NO If so, What Housing Authority? City & State of Housing Authority: What years? Have you ever lived in any Public Housing through another Housing Authority? YES NO If So, What Housing Authority? City & State of Housing Authority: Name of Housing Project: What years? Do you currently owe another Housing Authority any money? Name: Signature: :

8 Authorization For Release of Information CONSENT: I authorize and direct any Federal, State or local agency, organization, business, or individual to release to the Winnebago County Housing Authority any information or materials needed to complete and verify my application for participation, and/or 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 Residences and Rental Activity Medical or Child Care Allowances Credit and Criminal Activity GROUPS OR INDIVIDUALS THAT MAY BE ASKED: The groups or individuals that may be asked to release the above information include, but are not limited to: Previous landlords Past & Present Employers Veterans Administration Welfare Agencies Retirement Systems Courts & Post Offices State Unemployment Agencies Banks & other Financial Institutions Schools & Colleges Social Security Administration Credit providers and Credit Bureaus Law Enforcement Agencies Medical and Child Care Providers Utility Companies Support & Alimony Providers COMPUTER MATCHING NOTICE AND CONSENT: I understand and agree that HUD or the Public Housing Authority may conduct computer matching programs to verify the information supplied for my application or re-certification. If a computer match is done, I understand that I have a right to notification of any adverse information found 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, Department of Defense, office of Personnel Management, the U.S. Postal Service, the Social Security Administration; and State Welfare 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 one month from the date signed. Head of Household: : Other Adult: Other Adult: : :