Ingham County Housing Commission Mainstream Housing Choice Voucher Application. Ingham County Housing Commission 3882 Dobie Road Okemos, MI 48864

Transcription

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

2 INGHAM COUNTY HOUSING COMMISSION APPLICATION FOR HOUSING SERVICES 3882 Dobie Road Okemos, MI fax: TTY: 711 APPLICANT INFORMATION - PLEASE PRINT IN BLUE or BLACK INK Name (First, Middle, Last) Date of Birth Phone Number Current Address City State Zip Name of person and phone number where you can be reached. Relationship Leave a message? Marital Status: (circle one) Married Never Married Divorced Widowed Separated Any other name by which your or household member has gone by: PROVIDE ALL INFORMATION REQUESTED & ANSWER ALL QUESTIONS BELOW List yourself first and all other persons who will be living in your home. Include persons who are temporarily absent from your home due to military service, education or hospitalization. Race of Head of Household: A=Asian B=Black H=Hispanic N=Native American P=Hawaiian or Pacific Islander W=White O=Other NAME - List applicant first (Last, First, Middle) Relationship to you Date of Birth Mo/Day/Year Social Security Number Drivers License Number U.S. Citizen Y or N Sex M or F Non-Citizen ARN Number 1 Self Please complete for anyone Name of School: Address: Phone #: attending school. Is any person : If yes, who? Who? Who? Who? Disabled, blind or unable to work Pregnant Has any person been arrested of a crime? Has any person received benefits from another housing agency? Due Date: Where: Where: If you or anyone in your family is a person with disabilities, and you require a specific 2 accommodation in order to fully utilize our programs and services, please contact the Ingham County Housing Commission at (517) with the request.

3 EARNED INCOME: (Answ er all Questions) Include persons w ho are self-employed Name of person with earnings: Start Date Will employment continue? Employer Name & Address Monthly pay before taxes Monthly pay after taxes Average # of hours/week paid? Day of week paid Last pay date Weekly Twice a month Every 2 weeks Other Rate of Pay Tips/bonus rec'd Avg tips per week $ Hourly $ Salary $ Other Name of person with earnings: Start Date Will employment continue? Employer Name & Address Monthly pay before taxes Monthly pay after taxes Average # of hours/week paid? Day of week paid Last pay date Weekly Twice a month Every 2 weeks Other Rate of Pay Tips/bonus rec'd Avg tips per week $ Hourly $ Salary $ Other For any person listed above as working, please answer the following: Has this person been unemployed for one year or longer prior to becoming employed? Is this person participating in any type of economic self-sufficiency program? Has this person received TANF (welfare) benefits in the past six months, including one time payments? For any person listed above as working, please answer the following: Has this person been unemployed for one year or longer prior to becoming employed? Is this person participating in any type of economic self-sufficiency program? Has this person received TANF (welfare) benefits in the past six months, including one time payments? OTHER INCOME: Does anyone receive money from: If yes, who receives? Social Security Benefits (RSDI) Supplemental Security Income (SSI) Veterans' Benefits paid? W = weekly M=Monthly T=Twice a month E=Every other week O=Other (please state): Workers Compensation Other Disability Benefits Child Support Unemployment benefits Retirement Benefits Military Allotments DHS (FIA) Benefits - Indicate monthly amount DHS Case Number (s) Monthly Amount Claim # If yes, who receives? Monthly Amount Claim # State Qtrly $ State Qtrly $ paid 1. Who A m t T ype 3. Who A m t T ype 2. Who A m t T ype 4. Who A m t T ype paid Do you receive any other money? Please specify. 3

4 ASSETS: Complete this section by providing requested information, including assets held jointly. Does any person have any of the following: Name(s) on the account Name & address of bank or other financial institution Account Number Checking/Draft account Money Market Accounts Savings/Share Accounts Certificates of Deposits (CD) Christmas Club Accounts Other, please list Other, please list Does any person have any of the following: Cash on hand or in a safe deposit box Real Estate, including income producing property Mortgage, land contract or other notes payable to a household member Savings Bonds, Stocks or Mutual Funds IRA, KEOGH, 401K or Deferred Compensation Account(s) Trust Funds Life Insurance or Annuity Prepaid Funeral Agreements Has any person sold/given away property, land, stocks, bonds, cash, etc, closed any accounts, removed or added a name to an account within the last 24 months? If yes, give amount/value If yes, describe: Owner(s) Include cars, watercrafts, snowmobiles, motorcycles, quads, mobile homes, etc. Name of vehicle owner(s) as shown on vehicle title or registration Type of vehicle Year Color/Make/Model Balance Name & Address where asset is located VEHICLE INFORMATION: List all vehicles owned or titled in the name of any person living in the home. License Plate # DAY CARE EXPENSE - Please complete the following if you have a day care expense Name of Child needing care Reason care is needed Age Name and Address of Person(s) providing care: 1) Cost of Care paid Do you receive help paying for care (circle for each child) If yes, name of source providing the help & amount $ $ $ $ $ $ 2) 4

5 MEDICAL EXPENSES for Households whose head or spouse is Disabled or Elderly (over 62) Has anyone paid out-of-pocket (not reimbursed) for the following medical expenses? If yes, who? Any household member Who do you pay?? (circle response) Doctor Visits Prescriptions Vision Care Dental Medicare Premiums Supplemental Health Ins Transportation to a Health Care Provider Unpaid Old Medical Bills Other Medical Expenses - Please list expense and complete the questions: If yes, who? Any household member paid? Amount? Do you expect this expense to continue? Do you expect this expense to continue? (circle response) Please provide the name & address of all medical providers to the Ingham County Housing Commission ABSENT PARENT INFORMATION: Complete for each child who has a parent not in the home Name of Child Name of Absent Parent Address of Absent Parent Amount of Court Ordered Support Amount of support being paid (include cash payments) Do you receive a child support participation payment from DHS? If yes, amount. $ /month SIGNATURE CERTIFICATION: All adults in the home must sign this application. By signing, you are attesting that all information is true and correct, and that you understand all changes must be reported to the Ingham County Housing Commission in writing within TEN business days, including changes in income and household composition. Your signature also acts as a release for us to exchange information with the Department of Human Services for all program eligibility. Please sign at interview. Signature of Head of Household Date Signature of Spouse Date Signature of Other Adult Date Signature of ICHC employee Date NOTES: For office use only 5

6 First Last Middle Initial Social Security No.: Date of Birth: 1. Is the Head of Household or another family member enrolled in an employment training program or currently working full-time, or attending school on a full-time basis, or a combination of part-time work schedule and part-time school credit hours? YES NO 2. Is the Head of Household a Veteran and has been honorably discharged from any branch of the service. YES 3. Is the family with at least one adult who is employed and has been employed for 6 months? YES 4. Are you or your spouse disabled as per the Social Security definition? NO NO YES NO If Yes, Permanent or Temporary Name of Person with Earning: Name of Employer: Start Date: School attending (if applicable): Start Date: Credit Hours: SIGNATURE CERTIFICATION: All adults in the home must sign this application. By signing, you are attesting that all information is true and correct, and that you understand all changes must be reported to the Ingham County Housing Commission in writing within TEN business days, including changes in income and household composition. Your signature also acts as a release for us to exchange information with the Department of Human Services for all program eligibility. Please sign at interview. Signature of Head of Household Date Signature of Spouse Date Signature of Other Adult Date Signature of ICHC employee Date 6

7 Section 8 Mainstream Voucher Program What are mainstream program vouchers? Mainstream program vouchers enable families having a person with disabilities to lease affordable private housing of their choice. Mainstream program vouchers also assist persons with disabilities who often face difficulties in locating suitable and accessible housing on the private market. What families are eligible to apply for mainstream program vouchers? Only a family that includes a disabled person and is income eligible may receive a mainstream program voucher. Applicants will be selected from the Public Housing Authorities (PHA) housing choice voucher waiting list. How does a PHA determine if a family is income eligible for the mainstream program vouchers? The PHA compares the family s annual income (gross income) with the HUD-established very low income limit or low income limit for the area. The family's gross income cannot exceed this limit. How do families obtain an apartment once they have a voucher? It is the responsibility of a family to find a unit that meets their needs. If the family finds a unit that meets the housing quality standards, the rent is reasonable, and the unit meets other program requirements, the PHA executes a HAP contract with the property owner. This contract authorizes the PHA to make subsidy payments on behalf of the family. If the family moves out of the unit, the contract with the owner ends and the family can move with continued assistance to another unit How much rent do vouchers cover? The PHA pays the owner the difference between 30 percent of family income and PHA determined payment standard or gross rent whichever is lower. The family may choose a unit with a higher rent than the payment standard and pay the owner the difference. How do families obtain mainstream program vouchers? Families apply to the local PHA that administers this program. When an eligible family with a disabled person comes to the top of the PHAs housing choice voucher waiting list, the PHA issues a housing choice voucher to the family. * Link for local PHA: 7