POTTERVILLE HOUSING COMMISSION APPLICATION FOR HOUSING SERVICES

Transcription

1 POTTERVILLE HOUSING COMMISSION APPLICATION FOR HOUSING SERVICES 210 E. Main St Potterville MI fax: APPLICANT INFORMATION - PLEASE PRINT IN BLUE or BLACK INK Nam e (First, Middle, Last) Date of Birth Phone Num ber 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 accommodation in order to fully utilize our programs and services, please contact the Potterville Housing Commission at (517) with the request.

2 EARNED INCOME: (Answ er all Questions) Include persons w ho are self-employed Name of person with earnings: Start Date W ill employment continue? Employer Name & Address Monthly pay before taxes Monthly pay after taxes Average # of hours/week? Day of week Last pay date W eekly 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 W ill employment continue? Employer Name & Address Monthly pay before taxes Monthly pay after taxes Average # of hours/week? Day of week Last pay date W eekly Twice a month Every 2 weeks Other Rate of Pay Tips/bonus rec'd Avg tips per week $ Hourly $ Salary $ Other For any pe rson listed above as w orking, please a nsw er the follow ing: Nam e: Has this person been unemployed for one year or longer prior to becoming employed? Is this person participating in any type of econom ic self-sufficiency program? Has this person received TANF (welfare) benefits in the past six m onths, including one tim e payments? For any pe rson listed above as w orking, please a nsw er the follow ing: Nam e: Has this person been unemployed for one year or longer prior to becoming employed? Is this person participating in any type of econom ic self-sufficiency program? Has this person received TANF (welfare) benefits in the past six m onths, including one tim e payments? OTHER INCOME: Does anyone receive money from: If yes, who receives? Social Security Benefits (RSDI) Supplemental Security Income (SSI) Veterans' Benefits? W = w eekly M=Monthly T=Tw ice a month E=Every other w eek O=Other (ple as e s tate ): W orkers 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 # S t a t e Q t rly $ S t a t e Q t rly $ 1. W ho A m t T ype 3. W ho A m t T ype 2. W ho A m t T ype 4. W ho A m t T ype Do you receive any other money? Please specify. 2

3 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 Pre 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, w atercrafts, snow m obiles, m otorcycles, quads, mobile hom es, 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 ow ned or titled in the nam e of any person living in the hom e. 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 Do you receive help paying for care (circle for each child) If yes, name of source providing the help & amount $ $ $ $ $ $ 2) 3

4 MEDICAL EXPENSES for Households whose head or spouse is Disabled or Elderly (over 62) Has anyone 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 Un Old Medical Bills Other Medical Expenses - Please list expense and complete the questions: If yes, who? Any household member? 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 w ho 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 (include cash payments) Do you receive a child support participation payment from DHS? If yes, am ount. $ /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 Potterville Housing Commission, including changes in income, household composition and address. 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 4

5 AUTHORIZATION For Release of Information Consent: I authorize and direct any Federal, State or local agency, organization, business, or individual to release to the Potterville Housing Commission any information or materials needed to complete and verify my application for participation and/or to maintain my continued assistance under the Section 8 Housing Choice Voucher, Rental Rehabilitation, Low-Income Public and Indian Housing and/or any other housing assistance program(s). 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 Medical Providers Residences and Rental Activity Credit and Criminal Activity Child Care Allowances I understand that this authorization cannot be used to obtain any information about me that is not pertinent to my eligibility for and continued participation in a housing assistance program. GROUPS OR INDIVIDUALS THAT MAY BE ASKED: The groups or individuals that may be asked to release the above information (depending on program requirements) include but are not limited to: Previous landlords (including Past and Present Employers Veterans Administration Public Housing Agencies) Welfare Agencies Retirement Systems Courts and Post Offices State Unemployment Agencies Banks & other Financial Institutions Schools and Colleges Social Security Administration Credit Providers & Credit Bureaus Law Enforcement Agencies Medical and Child Care Providers Utility Companies Support and Alimony Providers Pharmacies 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 recertification. If a computer match is done I understand that I have a right to notification of any adverse information found and 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 Agencies, Department of Defense; Office of Personnel Management; the U.S. Postal Service; the Social Security Administration; and State welfare and food stamp agencies. CONDITIONS: I agree that photocopy of this authorization may be used for the purposes stated above. This authorization will stay in effect for a year and one month from the date signed. SIGNATURES PRINTED/TYPED NAME DATE Head of Household Adult member Adult Member Adult Member WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentation to any department of Agency of the U.S. as to any matter within its jurisdiction. 5