Emergency Housing Assistance Application

Transcription

1 Applicant Name: Issued From: ******OFFICE USE ONLY****** DO NOT WRITE IN THIS SPACE Date Submitted: Time Submitted: Received by: Emergency Housing Assistance Application Please make sure your application has all of the items listed in the boxed area complete before turning it into YNHA. Your application can not begin the process without the following, and will be considered incomplete. All Emergency Housing Assistance applications are reviewed on a first-come, first-served basis. There is NO Waiting List for emergency Housing Assistance. Name, Address, and Phone Numbers Social Security numbers and Birthdates (Copies of Social Security cards for all 6 years and over are required.) Enrollment Verification from a Federally Recognized Tribe for Head of Household or Yakama Enrollment for Children in the Household. (Copies of Enrollment Cards and/or document from Enrollment Office are required.) Report ALL INCOME for all 18 years of age and older, or signed Statement of Zero Income Verification of income must also be provided. Signatures - All 18 years and older need to sign their name on designated areas of the application. Including the Release of Information Form HUD Form Homeless: Attach Referral documentation from any of the following agencies: Yakama Nation Veterans Affairs Program, Yakama Nation Nak Nu We Sha Program, Yakama Nation Commodity and Energy Assistance Program, BIA/Social Services, Indian Health/Contract Care Service, Dept of Social and Health Services, State Child Protective Services, Red Cross, Yakama Tribal/Children s Courts, Yakama Tribal Council, etc. Near Homeless: Copy of eviction, 72-hour notice, or delinquent mortgage notice, documenting the amount due including any late fees; and a statement from the landlord or the financial institution verifying that payment will prevent the eviction. A copy of the lease or rental agreement (for rentals) or the mortgage statement or payment book (for homeowners) also may be required. A completed and signed Verification of Landlord/Mortgage Lender. Including IRS W-9 Request for Taxpayer form signed by the Land Lord/Mortgage Lender who will be receiving funds under this EHA Program Screening: Your application will go through a screening process for Total Household Income, Previous Tenant History, and YNHA may conduct Criminal Background Checks to confirm eligibility according to HUD regulations. If any derogatory information is found, you will receive a Disapproved Notice in the mail. NOTICE: Families who have already received assistance under the Emergency Housing Assistance program are not eligible to apply for additional assistance until 24 months from the date of their last application was approved. Applicants shall have no outstanding debts to the YNHA or shall have complied with an YNHA Payback Agreement. Applicants whose housing was terminated by YNHA within twenty-four (24) months of their application are not eligible. The unit for which the applicant is receiving assistance must not be an YNHA unit. Disqualifying factors: Registered Sex Offender convicted of a felony: sentenced or released in the last 5 years, documented criminal activity, violent activity, illegal drug-related activity, over $500 damages of YNHA property or YNHA paid lodging. Assistance may not be used to pay rent to an immediate family member (i.e., father, mother, son, daughter, husband, wife, sibling, or any other person residing in the applicant s household).

2 YAKAMA NATION HOUSING AUTHORITY 611 South Camas Avenue, P.O. Box 156, Wapato, WA Phone: Fax: EMERGENCY HOUSING ASSISTANCE PROGRAM APPLICATION This Program pays one month s rent or mortgage payment for low-income Indian families who do not live in YNHA housing are in immediate need of shelter because they are Homeless or Nearly Homeless under the Program Policies. Except for cases of domestic violence, this does not include persons who have housing but are relocating or choosing to move out of housing they share with others. To be eligible for this Program, the Head of Household must be enrolled member of a federally-recognized Indian tribe, or the household must include children who are enrolled Yakama Tribal members. Service area: Yakama Reservation, Yakima, Benton, Klickitat, Skamania, and Kittitas Counties. This application must be completed in full. All persons age 18 or older must sign in all designated areas. You must provide Social Security Cards for all family members over age 6. Please inform YNHA if you need assistance to complete this application or if you are an individual with a disability in need of reasonable accommodation to complete this application. APPLICANT INFORMATION Name: Home Phone: Mailing Address: City/State/Zip: Physical Address: City/State/Zip: Message Phone: Work Phone: LIST ALL PERSONS IN YOUR HOUSEHOLD Name Relationship to Head of Household SELF Tribal Enrollment No. or CDIB Social Security Number Date of Birth CHECK ALL THAT APPLY: I have no home or permanent structure where I reside and I am homeless. I reside in a home but actual or threatened domestic violence makes living in the home unsafe. I am facing immediate eviction from a home or rental unit unless I receive assistance under this program. There are children in my household. My medical needs or those of a member of my household contribute to the need for housing.

3 THIS PAGE MUST BE COMPLETED BY ALL PERSONS AGE 18 OR OLDER. DOCUMENTATION OF INCOME SUCH AS PAY STUBS, AWARD LETTERS, ETC., MAY BE REQUIRED. THOSE WITH NO INCOME MUST SIGN BELOW. INCOME FROM EMPLOYMENT AND/OR SELF-EMPLOYMENT Name Job Title Name of Employer Pay Schedule (weekly, biweekly, monthly) Hours per Week Hourly Rate Tips or Commission INCOME FROM OTHER SOURCES Income Source Unemployment Benefits $ Applicant Amount Spouse Amount Other Adult Amount Other Adult Amount Labor & Industry Benefits $ Retirement/Pension Benefits $ Veteran s Benefits $ Social Security Benefits (SSB) $ Social Security Income (SSI) $ Child Support or Alimony $ Lease Income $ TANF/GA-U $ General Assistance (GA) $ Other Income (please explain) $ STATEMENT OF NO INCOME I,, do not have any income, whether from employment, payments from public assistance (DSHS/GA), unemployment, Social Security or SSI, lease income, childcare/babysitting, or any other type of income. I understand that providing false or inaccurate information is a crime under Federal, State, or Tribal law. Signature Date Social Security No. I,, do not have any income, whether from employment, payments from public assistance (DSHS/GA), unemployment, Social Security or SSI, lease income, childcare/babysitting, or any other type of income. I understand that providing false or inaccurate information is a crime under Federal, State, or Tribal law. Signature Date Social Security #

4 REASONS FOR APPLYING: Homeless- I am currently homeless (no home or permanent structure where I reside) and I have no other resources or support networks to obtain housing. Please explain: I am living in a home, but due to actual or threatened domestic violence make the home unsafe. Please explain: Documentation required: Copy of new lease or other document showing the name, address and telephone number of the landlord and the amount of one month s rent and any security deposit(s) required for new tenancy. Verification of Landlord. Documentation requested: Statement from referring agency; copies of police reports (domestic violence). Nearly Homeless- I have received an Eviction Notice from my Landlord for unpaid rent and I am facing immediate eviction unless I receive assistance under this Program. Please explain: I have received a Notice of Foreclosure from my Lender for nonpayment and I am facing immediate foreclosure unless I receive assistance under this Program. Please explain: Documentation required: Copy of the Eviction Notice showing the date of eviction and the amount due to avoid eviction. Lease showing the name, address, and telephone number of the Landlord and the amount of one month s rent and security deposit, if applicable. Documentation required: Mortgage statement and/or payment coupon or other document showing the name, address and telephone number of the lender and the amount of one month s mortgage payment; copy of the notice of foreclosure showing the amount due to avoid foreclosure. Additional information you like to have considered:

5 ALL PERSONS AGE 18 OR OLDER MUST READ CAREFULLY AND SIGN BELOW: I do hereby swear and attest that all of the information given on this application is true and correct. I fully understand and agree that YNHA will rely on this information in determining my eligibility for assistance under this program. I agree to cooperate in supplying all requested information in order to determine my eligibility, level of benefits, or verify my circumstances, including attending any scheduled appointments and completing and signing any requested forms. I understand that my failure to do so may result in the delay or disapproval of assistance under this program. I understand and agree that program assistance may not be used to pay rent to an immediate family member and that the housing assisted under this program must be used as my principal residence and not sublet to another person. I understand that YNHA is not able inspect each residence and that I am responsible for doing my own inspection and selecting lodging that meets my needs prior to submitting the Verification of Landlord to YNHA. I further understand and agree that if I knowingly provide false, incomplete or inaccurate information, I will be subject to criminal prosecution under Federal, State, and/or Tribal law, (including under Title 18, Section 1001 of the U.S. Code) and will repay to YNHA any program assistance received. Signature of Head of Household Date Signature of Spouse or Other Adult Date Signature of Other Adult Date Signature of Other Adult Date

6 Authorization for the Release of Information PHA requesting release of information: (Name, Address & Phone Number) YAKAMA NATION HOUSING AUTHORITY P.O. BOX 156 WAPATO, WA (509) U.S Dept. of Housing & Urban Development Office of Housing Office of Public and Indian Housing This form cannot be used to request a copy of a tax return. Instead, use IRS Form 4506, Request for Copy of TAX Form. Purpose: Individuals Or Organizations That May Release Information The U.S. Department of Housing and Urban Development Any individual or organization including any governmental (HUD) and the above named organization may use this organization may be asked to release information. For authorization and the information obtained with it, to example, information may be requested from: administer and enforce program rules and policies. Banks and Other Financial Institutions Authorization: Courts I authorize the release of any information (including Law Enforcement Agencies documentation and other materials) pertinent to eligibility for Credit Bureaus or participation under any of the following programs: Employers, Past and Present Low-Income Rental Indian Housing Landlords Low-Income Rental Public Housing Provider of: Mutual Help Homeownership Opportunity Program Alimony Rental Assistance Program (RAP) Child Care Rent Supplement Child Support Section 8 Housing Assistance Payments Program Credit Section 23 and 10 ( C ) Leased Housing Handicapped Assistance Section 23 Housing Assistance Payments Medical Care Section 202 Pensions/Annuities Section 221(d)(3) Below market Interest Rate Schools and Colleges Turnkey III Homeownership Opportunities Program U.S. Social Security Administration U.S. Department of Veterans Affairs I authorize the above named organization and HUD to obtain Utility Companies information about me or my family that is pertinent to Welfare Agencies eligibility for or participation in assisted housing programs. Computer Matching Notice & Consent I agree that a Public Housing Agency, Indian Housing I authorize only HUD, an Indian Housing Authority, or a Authority, or HUD may conduct computer matching Public Housing Agency to obtain information on wages or programs with other governmental agencies including unemployment compensation from State Employment Federal, State, Tribal, or local agencies. The governmental Securities Agencies. Agencies include: U.S. Office of Personnel Management Information Covered Inquiries may be made about: U.S. Social Security Administration Child Care Expenses U.S. Department of Defense Credit History U.S. Postal Service Criminal Activity State Employment Security Agencies Family Composition State Welfare and Food Stamp Agencies Employment, Income, Pensions, and Assets The match will be used to verify information supplied by the Federal, State, Tribal, or Local Benefits family. Handicapped Assistance Expenses Conditions Identity and Marital Status I agree that photocopies of this authorization may be used Medical Expenses for the purposes stated above. Social Security Numbers Residences and Rental History If I do not sign this authorization, I also understand that my housing assistance may be denied or terminated. Signature, Printed Name of Head of Household & Date Signature, Printed Name of Other Adult Member of the Household & Date: Signature, Printed Name of Other Adult Household Member & Date: Signature, Printed Name of Other Adult Member of the Household & Date: Original is retained by the requesting organization. Form HUD 9886 (4/91) ref. Handbooks , ,

7 YAKAMA NATION HOUSING AUTHORITY 611 South Camas Avenue, P.O. Box 156, Wapato, WA Phone: Fax: EMERGENCY HOUSING ASSISTANCE PROGRAM VERIFICATION FROM LANDLORD/LENDER TO: Print Name of Landlord/Manager ( Landlord ) or Mortgage Lender ( Lender ) Address City/State/Zip Landlord Phone (required) ( Applicant ), who resides at (the Residence ) is applying to the Yakama Nation Housing Authority for Emergency Housing Assistance. This Verification must be completed by the LANDLORD OR LENDER in order for the application to be completed. Please provide the following information: 1. Please check one and complete the paragraph that applies: The Landlord has a rental agreement with the Applicant for a house or apartment at for which the monthly rent is $. The Applicant owes $ in past due rent for the following month(s). The Landlord has notified the Applicant that the rental agreement will be terminated and the Applicant evicted unless a payment of $ is made on or before. Attach signed copies of Rental Agreement and Eviction Notice. Lender has a loan to the Applicant secured by a mortgage for the purchase of a home at, for which the monthly payment is $. The Applicant owes $ in past due mortgage payment for the following month(s). The Lender has notified the Applicant that the mortgage will be foreclosed unless a payment of $ is made on or before. Attach signed copies of the note and Mortgage, a statement or payment coupon showing the amounts due, and a Notice of Foreclosure. The Landlord owns or operates a residence or lodging at (address) is available to house the Applicant beginning (date).

8 (Continued from page 7) All required applications have been processed and approved and no further approvals are required (e.g., application for tenancy, credit applications, etc.) The monthly rental amount is $. 2. The Landlord or Lender agrees to accept a one-time payment of $ directly from the Yakama Nation Housing Authority on behalf of the Applicant and, as a condition of accepting such payment, agrees that (please check and complete the applicable paragraph): The Landlord will rescind the notice of termination or eviction and permit Applicant to continue to reside at the residence through. (date). The Landlord will provide one month s rental or lodging to the Applicant for the period beginning date and ending date. The Lender will rescind the notice of foreclosure and permit Applicant to continue to reside at the residence through (date). 3. The Landlord or Lender is not an immediate family member of the Applicant, nor does the Landlord or Lender reside with the Applicant or in the Applicant s household. 4. The Landlord or Lender has completed the IRS W-9 Request for Taxpayer Identification Number and Certification. The form is attached to this applicant. 5. The Landlord has complied and will comply with all the applicable state, local, and Tribal statutes, ordinances and codes that apply to the letting of the rental or lodging to be paid with funds under this program. This includes, without limitation, any applicable laws concerning lead hazards or standards for habitability. 6. The Landlord understands and agrees that the Yakama Nation Housing Authority assumes no duty whatsoever to the Landlord by providing the payment on behalf of the Applicant. 7. If for whatever reason the Applicant does not obtain rental or lodging from the Landlord, the Landlord agrees to return all monies paid by YNHA directly back to YNHA. 8. The Landlord or Lender understands that these are Federal Funds made available through grants from the U.S. Department of Housing and Urban Development (HUD) and that providing false or misleading information to obtain Federal Funds is a Federal Offense. By signing below, I hereby represent that I am either the Landlord or Lender (or authorized to sign this form on behalf of Landlord/Lender) and that the information provided above is true and correct and that I understand that the Yakama Nation Housing Authority will rely on these statements in determining whether to authorize a payment to the Landlord or Lender on behalf of the Applicant. I also understand that these are Federal Funds made available through grants from the U.S. Department of Housing and Urban Development (HUD) and that providing false or misleading information to obtain Federal Funds is a Federal Offense. Authorized Signature Printed Name of Landlord/Lender Date Title