TEAR OFF THIS TOP SHEET AND RETAIN FOR YOUR INFORMATION

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Denis Taylor
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** TEAR OFF THIS TOP SHEET AND RETAIN FOR YOUR INFORMATION** An application for the Public Housing Program is attached. NO EMERGENCY HOUSING is available.

1 ** TEAR OFF THIS TOP SHEET AND RETAIN FOR YOUR INFORMATION** An application for the Public Housing Program is attached. NO EMERGENCY HOUSING is available. We must serve all applicants in order by placement on the list. Complete the application in ink pen. Fill out all sections of the application. Carefully list your complete mailing address and telephone number so we can contact you when necessary. If you do not have a stable address or telephone number, list a mailing address and telephone number where you are sure to get your mail and calls. If the application is not complete and we are not able to contact you, your name will not be placed on the waiting list and the application will be shredded. After we review the application and your information is entered into our data base in the computer, within 30 45, days you will receive an appointment letter. Youngstown Metropolitan Housing Authority is an Equal Housing Provider Youngstown Metropolitan Housing Authority does not discriminate against any faith based organization nor any person on the basis of race, color, religion, sex, national or ethnic origin, disability, age, marital status, genetic information, or any other protected characteristic or factor. IMPORTANT: Report all changes to your application in writing within ten (10) days because it may affect your placement on the waiting list. Due to the high volume of customers, we are unable to see applicants without an appointment and ask that you do not call to check the status of your application. You will be contacted in writing of your appointment date and time. NO emergency housing is available. 131 West Boardman Street Youngstown, OH Fax TDD:

2 Youngstown Metropolitan Housing Authority 131 West Boardman Street, Youngstown, OH (330) Housing Eligibility Application Form FOR YMHA USE ONLY Date: Time: Head of Household (Legal Name) Last First MI Sex SSN Date of Birth Age Race: White Black/African American American Indian/Alaska Native Asian Native Hawaiian/Other Pacific Islander Ethnicity: Hispanic n-hispanic Do you require any modifications or accommodations in order to fully utilize the unit or the program and its services? Yes Which of the following housing programs are you applying for? Public Housing New Construction Lowellville Park Apartments Are you a Veteran of the U.S. Armed Forces? Yes Dates of Service Branch of Service Present Address Information Street Address Street City State Zip Mailing Address Street City State Zip Home Tel. ( ) Business Tel. ( ) Landlord: List previous street address before moving to the address listed above. Street Address Street City State Zip List a contact person that we may contact if the Housing Authority is unable to reach you. Name Tel. Address Relation Household members: List the legal names of all household members who will be living with you. Start with the head of household, then spouse or co-head, then minors (oldest to youngest) and then any other adults. No. Legal Name Sex Relationship to Head SSN Date of Birth Age Disabled Yes/No? Page 1 of 5 Revised 6/2010 mlo

3 Marital Status Information (Copies of Separation of Divorce papers must be provided) Marital Status: Single Married Separated Divorced Widowed Wife s Maiden Name: Name of Former Wife/Husband Separation Date: Divorce: Deceased Date: Absent Parent(s) of dependent child: Name: Employment Information: For each family member (where applicable) show source and anticipated income. List all income sources for verification. Family Member Place of Employment Current Wages (Monthly/Weekly) Hourly Rate Hours Worked Annual Earnings Does any family member work for anyone who pays him or her cash? Yes Monthly Amount: Does anyone outside of your household pay any of your bills or expenses? Yes If yes, explain: Did you file a Federal Income Tax Return for the most recent year? Yes Do you own any property? Yes Have you disposed of any assets within the last two (2) years? Yes If yes, explain: Financial Assistance: List all income sources for verification during the admissions process Family Member Child Support Veterans SSI SSA Unemployment Other Monthly Monthly Monthly Annual Amount Asset Information (Property/Stocks/Bonds/CD s) Family Member Asset Description Market Value Cash Value Interest Rate Annual Income Banking Information Name of Bank Account Number Type (Checking/Savings) Joint/Individual Balance Page 2 of 5

4 Program Integrity Information Do you expect anyone to move in or out of your household within the next 12 months? Yes Does anyone live with you now who is not listed above? Yes Do you anticipate any changes in your family size? Yes If yes, what changes? Have you ever lived in rent assisted housing before? (Public Housing, Housing Choice Voucher Program (Section 8) or other) Yes If yes: When? Where? Under what name? Who was the head of household? Have you ever used a name other than the one you are using now? Yes If yes, what name? Have you ever used a social security number other than the one listed above? Yes If yes, what is it? Have you ever been evicted from Public or any other assisted housing for violent criminal or drug related activity? Yes Have you ever violated a family obligation in a HUD-assisted housing program? Yes Do you owe money to a Public Housing Agency? Yes Current Expenditures Rent Phone Medical Disability Electric Auto Payment Cable Credit Card Gas Auto Insurance Insurance Loan Water Child Care Rentals Other Do you have any other regular monthly payments besides those above? Yes If yes, please specify: Work History Where was the last place of employment for all adult household members? Family Member From (year) To (year) Employer. Pets Do you have any pets? Yes If yes, what kind: Size: Weight: Vehicles: How many vehicles does the family own? Owner Make Model Year Color Tag # State Page 3 of 5

5 Marketing: How did you hear about YMHA? (Check one or more below) Newspaper Radio Television Friend Referral Other: Citizenship Are you a citizen of the United States? Yes You will be required to complete Appendix A: Declaration of Section 214 Status (Citizenship) Primary Language (Please check) English Spanish Other Criminal History 1) Have you ever been charged or convicted of a felony or violent crime? Yes 2) Have you ever been charged or convicted of a drug-related offense? Yes If the answer to either is yes, please provide the details: 3) Are you subject to a lifetime registration requirement under a state sex offender registration program in the United States? Yes 4) Is anyone in your household subject to a lifetime registration requirement under a state sex offender registration program in the United States? Yes Applicant Certification I/we certify that the information given above is accurate and complete to the best of my knowledge and belief. I/we understand that any attempt to obtain housing through the Public Housing Program or Section 8 New Construction, 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 under federal law. I/we also understand that all changes in the income of any family member of the household as well as any changes in the household members must be reported to YMHA in writing within 10 days from the date of the change. RELEASE: I hereby authorize the requested information. Information obtained under this consent is limited to information that is no older than 12 months. There are circumstances that would require the owner to verify information that is up to 5 years old, which would be authorized by me on a separate consent attached to a copy of this consent. Head of Household Date Signed Co-Head/Spouse Date Signed Housing Specialist Date of Interview Date Signed Note to Applicant/Tenant: You do not have to sign this form if either the requesting organization or the organization supplying the information is left blank. PENALTIES FOR MISUSING THIS CONSENT: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposes cited above. Any person who knowingly or willingly requests, obtains, or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages and seek other relief, as may be appropriate, against the officer or employee of HUD or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the **Social Security Act at 208 (a) (6), (7) and (8). Violations of these provisions are cited as violations of 42 U.S.C. 408 (a) (6), (7) and (8).** Page 4 of 5

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We Do Business in Accordance to the Federal Fair Housing Law

We Do Business in Accordance to the Federal Fair Housing Law PLEASE COMPLETE IN FULL SW Florida Affordable Choice Foundation, Inc. Application for Covington Meadows Covington Meadows Circle, Lehigh Acres, FL 33936 Telephone (239) 344-3220 Fax (239) 344-3273 TDD