Mt. Shasta Security Deposit Assistance Program
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1 Mt. Shasta Security Deposit Assistance Program The Security Deposit Assistance Program (SDAP) is a Community Development Block Grant (CDBG) funded program for households living within the city limits of Mt. Shasta. To be eligible for participation, applicants annual income must be below the median household income limit by size of household (see chart below for current income limits). Third party income verification will be required as part of application processing. Because of the level of income verification required by the Department of Housing and Community Development, please allow at least 60 days to process your application. This program will assist eligible applicants with security deposit funds for an amount not to exceed 2 (two) months rent or 2,000 (two thousand dollars), whichever is less. Additionally, applicants must provide a copy of a signed lease for one year (minimum). Assistance is made on behalf of the participant. No funds will go directly to participants. If the funds have been distributed on behalf of the participant and the participant terminates their lease early, it is the participant s responsibility to repay the deposit funds to the City of Mt. Shasta. Household Size "80%" Limit 30,650 35,000 39,400 43,750 47,250 50,750 54,250 57,750 PARTICIPANT INFORMATION FORM Please complete the following Participant Information Form. This information will help us determine your assistance. Date Name of Head of Household Current Address Mailing address (if different) Telephone Number ( ) Home Cell Work Other Telephone Number ( ) Home Cell Work Other Address Are you currently receiving ANY form of rental assistance? If YES please describe I would like to be contacted by 1
2 HOUSEHOLD MEMBER INFORMATION Starting with Box 1 for Head of Household, please supply the following information for all adults and children that will live in the housing unit to be assisted. List adults first, then children. Enter one of the following codes in Box 6 to identify the household relationship of each adult and child listed. H = Head of household K = Co-Head of household Y = Youth under 18 S = Spouse (married) F = Foster Child/Adult E = Full time student over 18 A = Other adult 2
3 Info on Unit to Be Occupied by Assisted Family Property Owner Information Assisted Unit Information Name Rental Address Address City City State ZIP State ZIP Home phone number Work phone number 3
4 4
5 Participant Asset Information Has any member of the family given away or disposed of assets valued at more than 1,000 for less than fair market value during the past two years? List household assets held by any family member, irrespective of age, in the space provided below. An asset is any one of the following types without limitation: 401(k) or 403(b) Checking Account Life Insurance Policies Pensions Stocks Bonds IRA Money Market Account Real Property Trust Fund Certificate of Deposit Mutual Funds Trust Funds Savings Account Required: Provide current statements showing the value and interest rate of each asset and check the provided box for each income. Head of household must sign this form certifying accuracy of information provided I certify under penalty of perjury that to the best of my knowledge, the information contained in these forms is true and correct. X Date 5
6 Authorization for Release of Information Consent I authorize and direct any Federal, State, or local agency, organization, business or individual to release to Great Northern Services (GNS) any information or materials needed to complete and verify by application for participation in the City of Mt. Shasta Security Deposit Assistance Program. 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 Community Development in administering and enforcing program rules and policies. Information Covered I understand that that verification and inquires that may be requested include but are not limited to: Identity and Marital Status Residences and Rental Activity Employment, Income and Assets Credit and Criminal Activity I understand that this authorization cannot be used to obtain any information that is not pertinent to my eligibility for this Security Deposit Assistance Program. Groups or Individuals that may be asked The following groups that may be asked to release the above information include, but are not limited to: Previous Landlords Schools and Colleges Support and Alimony Providers Retirement Systems Welfare Agencies Banks and Financial Institutions Past and Present Employers Credit Providers and Credit Bureaus State Unemployment Agencies Social Security Administration Veterans Administration Utility Companies Conditions I agree that a photocopy of this authorization may be used for the purposes stated above. The original of this authorization is on file with GNS and will stay in effect for a period of 12 months from the date signed. I understand I have a right to review my file and correct any information that I can prove is incorrect. X Head of Household X Spouse/ Co-Head of Household X Adult Member Signature Date Date Date 6
AUTHORIZATION FOR RELEASE OF INFORMATION CONSENT I authorize and direct any Federal, State or local agency organization, business, or individuals to r
AUTHORIZATION FOR RELEASE OF INFORMATION CONSENT I authorize and direct any Federal, State or local agency organization, business, or individuals to release to Scott County Community Development Agency
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Tuition Assistance Application For the School Year Beginning August 2019
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ST. LAWRENCE COUNTY OFFICE OF INDIGENT DEFENSE 48 Court Street, Canton, New York Telephone:
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Tenant Data Release of Information
TH E MUNICIPAL HOUS I NG AGENCY Tenant Data Release of Information For: Applicant's Name Social Security Number I hereby authorize the landlord or landlord's agents to verify the information on the application.