THE HOUSING AUTHORITY

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THE HOUSING AUTHORITY OF THE CITY OF LAWRENCEVILLE 502 Glenn Edge Drive Lawrenceville, Georgia 30046 www.lawrencevilleha.

1 THE HOUSING AUTHORITY OF THE CITY OF LAWRENCEVILLE 502 Glenn Edge Drive Lawrenceville, Georgia Lejla Slowinski Executive Director Phone: (770) LAWRENCEVILLE HOUSING AUTHORITY APPLICATION FOR HOUSING ALL APPLICATIONS FOR HOUSING ARE DUE BY MAY 29, 2014 When you return this application, you must provide copies of the following or your application will not be processed: Birth certificates, or proof of citizenship and/or eligible immigration status Social Security cards for all household members Picture ID for everyone 18 or older Proof of ALL sources of household income, including employment, social security, SSI, TANF, child support, unemployment and any other sources Everyone 18 or older Must print and sign the following forms: Authorization and Consent Form MUST BE NOTARIZED. A notary will be available Mon.-Thurs. at a cost of $2.00 to notarize this form. Authorization for Release of Information form Authorization for the Release of Information/Privacy Act Code of Georgia Fraud Form Application/Resident Certification Smoke free compliance Barriers to Housing Stability Assessment (1 per household) WARNING! Title 18, Section 1001 of the United States code, states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any Department or Agency of the United States.

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3 AUTHORIZATION AND CONSENT I hereby state that the information given by me in my application for housing is true and complete in all respects, and I agree that if any information therein is found to be false or incomplete at any time and any respect, I will be subject to rejection of my application or termination of my lease agreement. I understand that in consideration of my application, an investigation may be conducted of my past employment. I authorize employers, personnel references and any other persons with whom I am acquainted to answer all questions asked concerning my previous employment record, character, reputation, medical and worker s compensation history, military service, credit history, criminal history, and mode of living. I release all persons, including past employers, credit bureaus, and government agencies from any liabilities or damages or damages on account of having furnished such information in good faith. In consideration of my application for housing, I authorize the Housing Authority of the City of Lawrenceville and/or its agents to conduct such an investigation, and release the company named above, including its officers, employees, agents, and representatives from all liability or responsibility for this investigation, which may include, but is not limited to the gathering of information regarding personal, professional, credit or consumer investigations, driving histories, and any criminal history information which may be in the files of any state or local criminal justice agency. I understand that the information requested below regarding sex, race and date of birth are for the sole purpose of gathering the above information accurately, and will not be used to discriminate against me in violation of a law. A telephone facsimile (FAX) or a photographic copy of this authorization shall be as valid as the original. FAIR CREDIT REPORTING ACT PLEASE READ In making this application for housing, I understand that a consumer report may be requested or an investigation conducted to determine my suitability for housing. I further understand that if housing is denied in whole or in part because of information obtained by Housing Authority of the City of Lawrenceville from a consumer reporting agency, I have the right to make a written request within a reasonable period of time to receive information about the scope and nature of the investigation. APPLICANT S FULL NAME (PRINTED) SOCIAL SECURITY NUMBER MAIDEN OR OTHER NAME USED DRIVER LICENSE # STATE CURRENT ADDRESS DATE OF BIRTH SEX RACE CITY, STATE, ZIP SIGNATURE DATE DO NOT WRITE BELOW THIS LINE TO BE FILLED OUT BY NOTARY ONLY Subscribed and sworn before me this day of, Notary Signature NOTARY SEAL 3

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5 Authorization for Release of Information Requested by: Lawrenceville Housing Authority 502 Glenn Edge Drive Lawrenceville, GA Purpose: This information authorizes the Lawrenceville Housing Authority (LHA) to secure your signature and the signatures of each adult member of your household for the purpose of obtaining information about applicants, residents, and household members 18 years of age or older. Such information will be used to determine initial and continued eligibility for public housing. Authorization: I authorize the release of any information to the Lawrenceville Housing Authority (LHA), (including documentation and other materials) pertinent to eligibility for assisted housing benefits. I authorize LHA to obtain information about me or my family that is pertinent to eligibility and participation in public housing. I authorize LHA to obtain information on wages, social security, W-2, unemployment compensation, assets, bank statements, tax returns, daycare information, child support income, immigration status and other documents required for verification of my eligibility for program participation. Information covered inquiries may be made about: Credit history, including a credit report Family composition Employment, income, pensions, assets Federal, state, tribal or local benefits Social Security numbers Residences and rental history Agency or persons assisting applications Daycare costs Child support Immigration status Individuals, Organizations or Providers that may release information Any individual including any governmental organization, for-profit corporation, or nonprofit service provider may be asked to release information. For example: Landlords, past and present Employers, past and present Credit Bureaus Banks and other financial institutions US Social Security Administration US Department of Veteran s Affairs W-2 Agencies Alimony sources Pension/Annuity Sources Internal Revenue Service Federal, state, local or tribal law enforcement agencies Conditions: I agree that photocopies or fax copies of this authorization may be used for the purposes stated above. If I, or any adult member of my family, fail to sign this authorization, I understand that this action may constitute grounds for denial of eligibility or termination of assistance or residency, or both. Signature of Applicant Social Security Number THIS RELEASE EXPIRES 15 months after date of signature. 5

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7 Lawrenceville Housing Authority 502 Glenn Edge Drive Lawrenceville, GA (770)

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9 CODE OF GEORGIA : Fraudulently obtaining or attempting to Obtain Public Housing (a) Any person who obtains or attempts to obtain or who establishes or attempts to establish eligibility for, and any person who knowingly or intentionally aids or abets such person in obtaining or attempting to obtain or in establishing or attempting to establish eligibility for, any public housing or a reduction in public housing rental charges or any rent subsidy or payment from a tenant in connection with public housing to which such person would not otherwise be entitled, by means of a false statement, failure to disclose information, impersonation, or other fraudulent scheme or device shall be guilty of a misdemeanor. (b) As used in this Code section, 'public housing' means housing which is constructed, operated, maintained, financed, or subsidized by the state, a county, a municipal corporation, the Georgia Housing and Finance Authority, a housing authority, or by any other political subdivision or public corporation of the state or its subdivisions. (c) Notice of subsection (a) of this Code section shall be printed on the application form for public housing and shall be displayed in the office where such application is made. Code 1933, , enacted by Ga. L. 1977, p. 1332, 1,2; Code , as redesignated by Ga. L. 1980, p. 405, 2; Ga. L. 1989, p ; Ga. L. 1991, p. 1653, 2-3. This copy of the Code of Georgia is attached to your application for admission and made part of the application. Signature of Head of Household Signature Other Adult over 18 Witnessed 9

10 APPLICATION/RESIDENT CERTIFICATION APPLICANT(S)/RESIDENT(S) STATEMENT I/We certify that the information given to the Lawrenceville Housing Authority on household composition, income, net family assets, and allowances and deductions is accurate and complete to the best of my/our knowledge and belief. I/We understand that false statements or information are punishable under Federal Law. I/We also understand that false statements or information are grounds for termination of housing assistance and termination of tenancy. Signature of Head of Household Signature of Other Adult over 18 Witnessed If you believe you have been discriminated against, you may call the Fair Housing and Equal Opportunity National Toll-Free Hot Line at After verification by this Housing Authority, the information will be submitted to the Department of Housing and Urban Development on Form HUD A (Family report), a computer generated facsimile of the form or magnetic tape. See the Federal Privacy Act statement for more information about its use. 10

11 THE HOUSING AUTHORITY OF THE CITY OF LAWRENCEVILLE 502 Glenn Edge Drive Lawrenceville, Georgia Lejla Slowinski Executive Director Phone: (770) SMOKE FREE CERTIFICATION I understand that the Lawrenceville Housing Authority, including all buildings, units and grounds are SMOKE FREE. I also understand that any non-compliance to these rules will result in my eviction from the Lawrenceville Housing Authority. By signing below I agree that I will obey the Smoke Free policy of the Lawrenceville Housing Authority. Signature of Applicant Signature of other adult 18 or older Signature of other adult 18 or older 11

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13 BARRIERS TO HOUSING STABILITY ASSESSMENT This is a voluntary form that helps Gwinnett County assess the needs of its residents. Please complete and return with your application. AGENY: Lawrenceville Housing Authority Applicant Name: : Tenant Barriers Rental History: 1. Have you ever had a lease for an apartment or a home in your name? 2. Have you had utilities in your name? 3. How many times have you been evicted from housing? or more 4. Would a prior landlord(s) give you a bad reference? Credit History: 1. Do you have unpaid rent or utility bills in your name? 2. Do you have a credit history? 3. Do you have poor credit? Criminal History: 1. Have you ever been convicted of one or more misdemeanors? 2. Have you ever been convicted of a felony? 3. If yes, did the felony involve drugs, weapons, or a sex crime? 4. Are you currently on probation? 5. If yes, what is the date your probation expires? 13

14 (OFFICE COMPLETES THIS PART) Summary of impact of tenant barriers on housing: No effect Minimal effect Moderate effect Major effect Unknown Personal Barriers Family Composition: 1. Do you currently have more than four individuals in your household? 2. Do you currently have a male between the ages of in your household? Physical Health: 1. Have your physical abilities or physical health ever caused you to lose your housing? 2. Does your physical health or abilities currently affect your ability to get housing? Mental Health: 1. Do you have mental health issues that have caused you to lose your housing in the past? 2. Do you have mental health issues that currently affect your ability to get housing? Substance Use: 1. Has substance use (drugs or alcohol) caused you to lose your housing in the past? 2. Does current substance use affect your ability to get housing? Domestic Violence/Abuse: 1. Has domestic violence or abuse ever caused you to lose your housing in the past? 2. Does domestic violence or abuse currently affect your ability to get housing? (OFFICE COMPLETES THIS PART) Summary of impact of personal barriers on housing: No effect Minimal effect Moderate effect Major effect Unknown Income Barriers Income: 1. Do you have any regular income? (from a job, TANF, disability, child support, etc) at this time? 14

15 2. Do you need temporary assistance to get or keep housing? 3. Do you need permanent assistance to get or keep housing? 4. If you are living in a house or apartment, what percent of your income do you spend on housing (rent/mortgage AND utilities)? 35% or less 36-50% 51-65% 66-80% 80% or more Unknown 5. If you are not living in your own house or apartment, how much money can you spend on housing each month? $0 $1-100 $ $ $ $ $ $ $ more than $801 Unknown Other Income Related: 1. Are you currently receiving Social Security or Disability? Yes No Ineligible Unknown 2. Are you currently receiving TANF? Yes No Ineligible Unknown 3. Are you currently receiving assistance from the public housing authority? Yes No Ineligible Unknown 4. Are you currently receiving food stamps? Yes No Ineligible Unknown 5. Do you have a steady, full time job? 6. Do you have a high school diploma or GED? 7. Job barrier: Is English your second language? 8. Job barrier: Do you have a working car or other reliable transportation to get to work? 9. Job barrier: If you have small children, do you have affordable child care? Yes No Not applicable Unknown (OFFICE COMPLETES THIS PART) Summary of impact of income barriers on housing: No effect Minimal effect Moderate effect Major effect Unknown 15

# of people who will be living in unit: Application Denied

# of people who will be living in unit: Application Denied Rental Application Information on this application will be used to determine your eligibility to be a Project NOW housing resident. Fill out all sections completely. This application will not be processed