Recertification Questionnaire LIHTC Please print in ink, answer NO or N/A where applicable, initial all corrections, and do not use white out

Transcription

1 Recertification Questionnaire LIHTC Please print in ink, answer O or /A where applicable, initial all corrections, and do not use white out RESIDET IORATIO Tenant s ull ame: Apartment Community: Unit umber: HOUSEHOLD COPOSITIO Phone umber: DIRECTIOS: PLEASE COPLETE THE TABLE BELOW LISTIG EACH EBER O THE HOUSEHOLD, ICLUDIG CARE ATTEDATS, WHETHER OR OT THOSE EBERS ARE RELATED. ICLUDE ALL EBERS WHO OU ATICIPATE WILL LIVE WITH OU AT LEAST 50% OR ORE O THE TIE DURIG THE EXT 12 OTHS. (A ULL TIE STUDET IS AOE WHO IS EROLLED OR AT LEAST IVE CALEDAR EAR OTHS OR THE UBER O HOURS OR COURSES WHICH ARE COSIDERED ULL-TIE ATTEDACE B THAT ISTITUTIO. THE IVE OTHS EED OT BE COSECUTIVE). *LIST EACH PERSO LIVIG I THE UIT* ame Relation to Head Birth Date Gender Student Employed arital Status SS umber 1 HEAD arried 2 arried 3 arried 4 arried 5 arried 6 arried 7 arried Do all of the household members reside in the household 100% of the time? If no, please list those not living in the household 100% of the time: Anticipated changes in household size within the next 12 months? If yes, explain: Anticipated change in number of students within the next 12 months? If yes, explain:

2 2 of 5 DISABILIT STATUS Would you or anyone in your household benefit from the features of a handicap -accessible unit? Do you require any accommodations or modifications to the unit for any disability? If yes, explain: CARE ATTEDAT Will you have a Care Attendant living with you? If yes, or ame of Care Attendant: Address: City: State: ZIP: GEERAL IORATIO Have you, your spouse, or any other proposed occupant ever: 1. Been arrested and charged with a misdemeanor or felony? If yes, who in what state what year 2. Been required to register as a sex offender? If yes, who in what state what year 3. Been evicted? If yes, when where Do you have a Section 8 voucher or certificate? Do you have any pets? If yes, list breed and weight: *Only permitted in senior properties* EERGEC COTACT (PLEASE PROVIDE IORATIO OR TWO PEOPLE OT PLAIG TO OCCUP THE PREISES WHO WE A COTACT I THE EVET O A EERGEC, OR TO LOCATE OU) ame: Relationship: Address: City: State: Zip: ame Relationship: Address: City: State: Zip: AUTOOBILE IORATIO odel: ake: Color: Tag #: odel: ake: Color: Tag #:

3 3 of 5 CHA (orth Carolina Housing inance Agency) regulations require that all applicants/tenants reveal all sources of income and assets. This application is not considered complete and therefore cannot be processed until the following questionnaire of income and assets have been completed by each household member 18 years of age and older (not required for care attendants). AE: ICOE AD ASSETS (EACH HOUSEHOLD EBER 18 RS AD OLDER UST COPLETE SEPARATE ICOE AD ASSETS ORS) Type of Asset How any Estimated Value Source Contact for Verification (list each separately) Checking Account Savings Account Debit Cards OT including debit cards related to the accounts listed above Certificates of Deposits oney arket unds utual unds/stock Treasury Bills IRA or 401k Company Retirement Accounts Annuities Income Life Insurance Policies (Whole Life) Pension unds (Account ot received on a regular basis) Trust Accounts If yes, is it revocable? Personal Property held for Investment ortgage or Deed of Trust Cash on Hand House/Real Estate Rental Property Other Investments Have you received any lump sum payments such as the following: Inheritances Details: Lottery or other winnings Details: Insurance Settlements Details: Workers Compensation Settlements Details: Social Security Disability Settlements Details: Unemployment Compensation Settlements Details: VA Disability Settlements Details: Severance Pay Details: Capital Gains Details: Other Details: Have you disposed of any assets for less than air arket Value within the last two years? (Please state if the sale was due to foreclosure, bankruptcy or divorce.) If yes, explain:

4 4 of 5 Income Type of Income How any Estimated onthly Amount Source Contact for Verification Employment (Wages & Salary) Income from a Business or Profession ilitary Pay, including all allowances Social Security SSI TA/Work irst or other Public Assistance Alimony Child Support (include all support whether court ordered or not) Unemployment Compensation Workers Compensation Severance Pay Retirement Income Pensions (Received on a regular basis) Annuities Income Insurance Policies Income Scholarships, Grants, Educational Entitlements Work Study Programs Long Term Care Payments Income from Training Other Income Regular Recurring Gifts (Such as but not limited to: Receiving monetary gifts or non-cash contributions from persons outside the household for rent, utilities, groceries, clothing and/or misc household supplies) Please explain: I understand that the above information is being collected to determine my eligibility for residence. I authorize the owner/ manager to verify information provided on this application and my signature is my con sent to obtain such verification. I certify that I have revealed all assets currently held or previously disposed of and that I have no other assets other than those listed on this form (other than personal property). I further certify that the statement s made in this application are true and complete to the best of my knowledge and belief and am aware that false statements are punishable under ederal law. I understand that this questionnaire and all related inquires will be used only for its relevance to occupancy at this property and any misrepresentations may disqualify me for housing. Signature: Date:

5 5 of 5 TEAT RELEASE AD COSET I/We, the undersigned hereby authorize all persons or companies in the categories listed below to release without liability, information regarding employment, income, and/or assets to for (owner or agent) purposes of verifying information on my/our apartment rental application. IORATIO COVERED I/We understand that previous or current information regarding me/us may be needed. Verifications and inquiries that may be requested include, but are not limited to: personal identity; employment, income, and assets; medical or child care allowances. I/We understand that this authorization cannot be used to obtain any information about me/us that is not pertinent to my eligibility for and continued participation as a Qualified Tenant. GROUPS OR IDIVIDUALS THAT A BE ASKED The groups or individuals that may be asked to release the above information include, but are not limited to: Past and Present Employers Welfare Agencies Veterans Administration Previous Landlords (including State Unemployment Agencies Retirement Systems Public Housing Agencies) Social Security Administration Banks and Other inancial Support and Alimony Providers edical and Child Care Providers Institutions CODITIOS I/We agree that a photocopy of this authorization may be used for the purposes stated above. The original of this authorization is on file and will stay in effect for a year and one month from the date signed. I/We understand I/we have a right to review this file and correct any information that is incorrect. SIGATURES Applicant/Resident (Print ame) Date Co-Applicant/Resident (Print ame) Date Adult ember (Print ame) Date Adult ember (Print ame) Date OTE: THIS GEERAL COSET A OT BE USED TO REQUEST A COP O A TAX RETUR. I A COP O A TAX RETUR IS EEDED, IRS OR 4506, REQUEST OR COP O TAX OR UST BE PREPARED AD SIGED SEPERATEL.