Kahuku Elderly Hauoli Hale PUULUANA PLACE, KAHUKU, HI TELEPHONE (808) TDD (877)

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1 Kahuku Elderly Hauoli Hale PUULUANA PLACE, KAHUKU, HI TELEPHONE (808) TDD (877) RESIDENT SELECTION PLAN Kahuku Elderly Hauoli Hale consists of 64 units that provides housing for very low and extremely low income households 62 years and older, without regard to race, color, sex, creed, religion, national origin, physical or mental disability status, familial status, age, ancestry, marital status, source of income, sexual orientation or HIV status. SECTION 504 AND FAIR HOUSING ACT COMPLIANCE Section 504 of the Rehabilitation Act of 1973 prohibits discrimination on the basis of disability in any program or activity receiving federal financial assistance from HUD. The Fair Housing Act prohibits discrimination in housing and housing related transactions based on race, color, religion, sex, national origin, disability and familial status. Title VI of the Civil Rights Act of 1964 prohibits discrimination on the basis of race, color or national origin in any program or activity receiving federal financial assistance from HUD. Kahuku Elderly Hauoli Hale is an Equal Opportunity Housing Facility, admitting people in accordance with Local, State and Federal Fair Housing laws, HUD Section 8 Program Regulations, Low Income Housing Tax Credit Program (LIHTC) and the Affirmative Fair Housing and Marketing Plan (AFHMP) HUD Form All marketing, tenant selection and residential management policies and procedures shall be conducted in accordance with these laws. Management staff operates and administers the property to enable persons with disabilities to have equal access to participate in the program. Kahuku Elderly Hauoli Hale will ensure effective communications with applicants, residents, and the public to ensure that policies regarding how the property is operated do not adversely affect applicants, residents and the public. When a family member requires an accessible feature(s), policy modification, or other reasonable accommodation to accommodate a disability, Kahuku Elderly Hauoli Hale will provide the requested accommodation unless doing so would result in a fundamental alteration in the nature of the program or an undue financial and administrative burden. A reasonable accommodation is a change, exception, or adjustment to a program, service, building or dwelling unit that will allow a qualified person with a disability to: 1. Participate fully in a program; 2. Take advantage of a service; or 3. Live in a dwelling. To show that a requested accommodation may be necessary, there must be an identifiable relationship, or nexus, between the requested accommodation and the individual s disability. The requirement to provide a reasonable accommodation is present at all times throughout the tenancy of a person with disabilities, including during lease enforcement. Reasonable Accommodation Request forms are available upon request from management. The person named below has been designated to coordinate compliance with the nondiscrimination requirements contained in the Department of Housing and Urban Development s regulations implementing Section 504 (24 CFR, part 8 dated June 2, 1988). Catina Wilson, Compliance Director 2169 E. Francisco Blvd, Suite B San Rafael, CA Telephone TDD INCOME LIMITS To qualify for a unit, household s gross income may not exceed the maximum income limit per household size for the Very Low Income limit KS RSP rev

2 (50% AMI) as published annually by HUD. The income limits are attached and will be posted in the community s office. APPLICATION PROCEDURES Applications will only be distributed when the Waiting List is open. Applications will not be distributed when the Waiting List is closed. Applications will be available at the site during normal business hours or by requesting an application by telephone. Each applicant must complete an application and be willing to submit to a credit history, rental history, and criminal background inquiry, as well as income and asset verifications. All application entries are to be made in ink or typed. Corrections or changes are to be made by lining through the original entry and entering the correct data. Such changes must be dated and initialed by the person making the change. Signed and dated applications will be processed on a first-come, firstserved basis. The application must be completed and signed by the head of household and all household members over 18 before an applicant can be placed on the Waiting List. If an application is not completely answered, the date of it being fully completed will be the date that the application is considered accepted for rental purposes. PREFERENCES It is the policy of the Property that a preference does not guarantee admission. Every applicant must still meet the Property s Resident Selection Plan standards for acceptance as a resident. For units accessible to or adaptable for persons with mobility, visual or hearing impairments, households containing at least one person with such impairment will have first priority. Persons displaced by government action or a presidentially declared disaster will be given a preference on the waitlist. Forty percent (40%) of Kahuku Elderly Hauoli Hale Section 8 subsidized vacancies each year must be set-aside for households whose income does KS RSP rev not exceed 30% of the area median income ( extremely low-income ) as published by HUD. Therefore, persons lower on the waiting list could be offered an apartment first to satisfy this 40% regulation. To implement this preference we will select the first extremely low-income applicant on the waiting list (which may mean "skipping over some applicants with higher incomes) for the available unit, and then select the next eligible applicant currently at the top of the waiting list (regardless of income level) for the next available unit. As subsequent units become available, tenant selection continues to alternate between the next extremely low-income applicant and the eligible applicant at the top of the waiting list until the 40% target is reached. Where preferences apply, applicants with a verified preference will be moved to the top of the waiting list above persons without a preference. UNIT TRANSFER POLICY A Unit Transfer List is maintained for those residents who have been approved for transfer on the basis of: a change in household size or household composition; a deeper subsidy (Section 8); a medical reason certified by a doctor; or a need for an accessible unit. Additionally, Kahuku Elderly Hauoli Hale will pay for moving expenses for a unit transfer conducted due to a reasonable accommodation to a household member s disability. Transfers for accessibility or medical reasons will have priority over those for changes in household composition. Residents on the Unit Transfer List will have priority over the applicants on the Waiting List. OCCUPANCY GUIDELINES Occupancy guidelines are the criterion established for matching a household with the most appropriate size and type of apartment. Two plus one occupancy guidelines will be followed to avoid under or over utilization of the units as follows: 2

3 Bedroom Household Household Minimum Maximum To determine the proper bedroom size for which a household may qualify, the following household members are to be included: 1. All full-time members of the household, and 2. Live-in attendants. NOTE: Live-in attendants are subject to the criminal and landlord provisions of this plan with the exception of criteria that determines ability to pay rent. DISCLOSURE OF SOCIAL SECURITY NUMBERS All applicants for assistance and program participants must disclose the social security numbers (SSNs) assigned to themselves and all members of their household. Exemptions are provided for: Non citizens who do not contend eligible immigration status. Assistance to these household members will be prorated. Current participants who are 62 years of age or older as of January 31, 2010, whose initial determination of eligibility was begun before January 31, o Qualifying seniors are exempt from the SSN disclosure mandate for all future examinations, even if the senior moves to a new HUD-assisted property. Documents required in order to verify the SSNs include: A valid SSN card issued by the Social Security Administration; An original document issued by a federal or state government agency, which contains the name, SSN, and other identifying information of the individual; or, Other acceptable documents that are listed in Appendix 3 of the HUD handbook New household members under the age of 6 who already have a SSN are subject to the same disclosure and verification requirements as new household members who are at least 6 years of age. For new members KS RSP rev who have not been assigned a SSN, a 90 day period for verification is allowed. If the household does not provide the SSN and verification within 90 days due to unforeseen circumstances outside the resident s control, Kahuku Elderly Hauoli Hale will grant an extension of one additional 90- day period. Also, the entire household WILL lose its tenancy or assistance if one member of the household does not comply with the SSN disclosure requirements. RESTRICTION ON ASSISTANCE TO NON-CITIZENS By law, only US citizens and eligible non-citizens are eligible for rental assistance. All family members, regardless of age, must declare their citizenship or immigration status. The following documents are required: 1. Family Summary Sheet and Owner Summary Sheet (lists all household members who will reside in the assisted unit) 2. Citizenship Declaration (Each household member listed must complete. Parents will complete and sign for household members under 18) 3. Forms and/or evidence of citizenship/immigration status. Applicants that are U.S. Citizens must sign a declaration of citizenship and provide documents as proof of citizenship. Verification of the declarations will be completed. Please refer to the attached Required Documentation (Citizen and/or Non-Citizen Eligibility) sheet for a listing of documents that will be accepted. Applicants that are Non-citizens claiming eligible status must sign a declaration of eligible immigration status, consent form and provide a DHS-approved document. Please refer to the attached Required Documentation (Citizen and/or Non-Citizen Eligibility) sheet for a listing of documents that will be accepted. Non-citizens not claiming eligible immigration status must sign a declaration that they are not claiming eligible immigration status. The manager is required to verify the validity of documents submitted by the applicant with the Department of Homeland Security (DHS) through their automated verification system. An applicant that provides documentation but is later determined by the DHS to be invalid documentation will have the assistance removed for that household 3

4 member. Non-citizens age 62 and older must provide proof of age and sign a declaration that they have eligible immigration status. Mixed families, a family that contains both eligible and non-eligible members may receive prorated assistance. Applicants who hold noncitizen student visas and non citizens living with the student are considered ineligible for assistance. Applicants who cannot provide documentation of eligible immigration status at the time of the applicant interview will be given a 14 day period to provide this documentation, if they provide a certification that the documentation is temporarily unavailable. Provided that at least one family member has provided documentation, the family may move in with prorated assistance provided they are otherwise eligible. Families that are found to be ineligible have the right to appeal the decision. The notice of ineligibility will describe the applicants options. STUDENT RULE As of January 30, 2006, 24 CFR Parts 5, 880, 883, et al. Eligibility of Students for Assisted Housing under Section 8 of the U.S. Housing Act of 1937; Final Rule becomes effective. No assistance shall be provided under Section 8 of the United States Housing Act of 1937 (42 U.S.C. 1437f) to any individual who: o o o o o o Is enrolled as a student at an institution of higher education (as defined under section 102 of the Higher Education Act of1965 (20 U.S.C. 1002); Is under 24 years of age; Is not a veteran; Is unmarried; Does not have a dependent child; and Is not otherwise individually eligible, or has parents who, individually or jointly, are not eligible, to receive assistance under section 8 of the United States Housing Act of 1937 (42 U.S.C. 1437f) A student who can prove that he/she is independent from their parents and does not meet any of the criteria listed, may be eligible for assistance provided information can be documented and verified. For purposes of determining the eligibility of a person to receive assistance under section 8 of the United States Housing Act of 1937 (42 U.S.C 1437f), any financial assistance (in excess of amounts received for tuition) that an individual receives under the Higher Education Act of 1965 (20 U.S.C et seq.)) from private sources, or an institution of higher education (as defined under the Higher Education Act of 1965 (20 U.S.C. 1002), shall be considered income to that individual, except for a person over the age of 23 with dependent children or if the student is living with his or her parents who are receiving Section 8 assistance. If an ineligible student is a member of an applicant household or an existing household receiving Section 8 assistance, the assistance for the household will not be prorated but will be terminated. For a student to be considered independent of his or her parents, the student must meet ALL of the following criteria to be eligible for Section 8 assistance: o o o o Be of legal contract age under state law; Have established a household separate from parents or legal guardians for a at least one year prior to application for occupancy, or Meet the U.S. department of Education s definition of an independent student; Not be claimed as a dependent by parents or legal guardians pursuant to IRS regulations; and Obtain a certification of the amount of financial assistance that will be provided by parents, signed by the individual providing the support. This certification is required even if no assistance will be provided. A student with a disability receiving Section 8 assistance as of November 30, 2005 is exempt from the student restrictions. Any person with a disability who is a student at an institution of higher education applying to receive Section 8 assistance after November 30, 2005 is not exempt from the student restrictions. KS RSP rev

5 GROUNDS FOR REJECTION 1. Total family income exceeds the applicable income limits published by HUD or household fails to meet the minimum income limit. 2. Household cannot pay the full security deposit at move-in. 3. Household refuses to accept the second offer of a unit. 4. Household fails to respond to interview letters or otherwise fails to cooperate with the certification process. Failure to sign consent forms. 5. ANY adult household members fail to attend eligibility interview. 6. Applicant failed to provide adequate verification of income or we are unable to adequately verify income and/or income sources. 7. Unit assignment will NOT be the family s sole place of residency. 8. At least one family member is not a citizen, national or otherwise lacks eligible immigration status. 9. Family members failed to provide proof of a social security number. See Disclosure of SSN section of this plan. 10. Negative landlord references that indicate lease violation, disturbing the peace, harassment, poor housekeeping, improper conduct or other negative references against the household. 11. Evictions reported in the last 5 years. 12. History of late payment of rent that demonstrates more than 2 late payments of rent in a six-month period for the past two years. More than 1 NSF in a one-year period. 13. Any evidence of illegal activity including drugs, gang, etc. KS RSP rev Providing or submitting false or untrue information on your application or failure to cooperate in any way with the verification process. 15. Inappropriate household size for the unit available (see Occupancy Standards). 16. Households whose members include a student enrolled in an institution of higher education that does not meet the criteria of the Student Rule will be ineligible for Section 8 assistance. 5 CREDIT 17. Less than 50% of credit lines positive (i.e., if four (4) lines of credit, only one can be negative). Does not include medical bills or student loans. 18. Unpaid Collections and grossly delinquent due balances exceed Mortgage default or foreclosure. In these instances, a preliminary denial letter will be sent to the applicant household. The applicant household will be given 14 calendar days to provide additional information regarding the default and foreclosure. Were an applicant to demonstrate that they defaulted on a subprime loan when the monthly payment adjusted up significantly and if the applicant household s recent credit history is otherwise sound, a subprime default and foreclosure alone would not be cause for a final denial. 20. Filing of a bankruptcy in the last 3 years. 21. Any amount showing owed to a landlord or property management company. 22. Conviction of a felony CRIMINAL

6 23. Conviction of more than one misdemeanor in the past three (3) years. 24. Listed as a registered sex offender. 25. Conviction of any drug, violent or other criminal activity that would threaten the household safety or right to peaceful enjoyment of the premises. 26. History of violence or drug or alcohol abuse or other potentially disruptive behavior as evidenced by a record of conviction or by documented statements concerning current illegal use or sale of a controlled substance. 27. There is a reasonable cause to believe that a household member s behavior of abuse or pattern of abuse of alcohol may interfere with the health, safety and right to peaceful enjoyment by other residents. VIOLENCE AGAINST WOMEN ACT OF 2005 The Violence Against Women Act of 2005 (VAWA) applies to projectbased Section 8 units (Kahuku Elderly Hauoli Hale) and offers the following protections for both men and women against eviction or denial of housing based on domestic violence, dating violence or stalking: 1. An applicant s or program participant s status as a victim of domestic violence, dating violence or stalking is not a basis for denial of rental assistance or for denial of admission, if the applicant otherwise qualifies for assistance or admission. 2. An incident or incidents of actual or threatened domestic violence, dating violence or stalking will not be construed as serious or repeated violations of the lease or other good cause for terminating the assistance, tenancy, or occupancy rights of a victim of abuse. 3. Criminal activity directly related to domestic violence, dating violence or stalking, engaged in by a member of a tenant s KS RSP rev household or any guest or other person under the tenant s control, shall not be cause for termination of assistance, tenancy, or occupancy rights of the victim of the criminal acts. 4. Assistance may be terminated or a lease bifurcated in order to remove an offending household member from the home. Whether or not the individual is a signatory to the lease and lawful tenant, if he/she engages in a criminal act of physical violence against family members or others, he/she stands to be evicted, removed, or have his/her occupancy rights terminated. This action is taken while allowing the victim, who is a tenant or a lawful occupant, to remain. 5. The provisions protecting victims of domestic violence, dating violence or stalking engaged in by a member of the household, may not be construed to limit Kahuku Elderly Hauoli Hale when notified, from honoring various court orders issued to either protect the victim or address the distribution of property in case a family breaks up. 6. The authority to evict or terminate assistance is not limited with respect to a victim that commits unrelated criminal activity. Furthermore, if Kahuku Elderly Hauoli Hale can show an actual and imminent threat to other tenants or those employed at or providing service to the property if an unlawful tenant s residency is not terminated, then evicting a victim is an option, the VAWA notwithstanding. Ultimately, Kahuku Elderly Hauoli Hale will not subject victims to more demanding standards than other tenants. 7. The VAWA protections shall not supersede any provision of any federal, state, or local law that provides greater protection for victims of domestic violence, dating violence or stalking. The laws offering greater protection are applied in instances of domestic violence, dating violence or stalking. GRIEVANCE/APPEAL PROCESS Should the applicants fail to meet the screening criteria, they will receive a notice in writing indicating that they have the right to appeal the decision. 6

7 This notice must indicate that the applicant has 14 days to dispute the decision. An appeal meeting with the Property Supervisor or the Compliance staff will be held within 10 business days of receipt of the applicant s request. If the applicant is a person with disabilities, the owner must consider extenuating circumstances where this would be required as a matter for reasonable accommodation. Within five days of the appeal meeting, the property will advise the applicant in writing of the final decision regarding eligibility. Apartments will not be held for those applicants in the appeal process. ADMINISTRATION OF WAITING LIST The property is required to maintain a Waiting List of all eligible applicants. Applicants must be placed on the Waiting List and selected from the Waiting List even in situations where there are vacancies and the application is processed upon receipt. This procedure is necessary to assure the complete and accurate processing of all documentation for all applicants. Kahuku Elderly Hauoli Hale has one Waiting List that is established and maintained in chronological order based on the date and time of receipt of the Application. The Waiting List contains the following information for each applicant: 1. Applicant Name 2. Address and/or Contact Information 3. Phone Number(s) 4. Unit Type/Size 5. Household Composition 6. Preference/Accessibility requirements 7. Race/ Ethnicity (HUD) 8. Income Level 9. Date/Time of Application Applicants must report changes to any of the information immediately. PURGING THE WAITING LIST The Waiting List will be purged periodically. Each applicant will receive a letter from the property, which will request updated information and ask about their continued interest. This letter must be returned within the specified time or their application will be removed from the Waiting List. It is the responsibility of the applicant to maintain a current address with the office in order to receive waiting list correspondence. Any correspondence returned undeliverable will result in application being removed from the waiting list. OPENING/CLOSING OF WAITING LIST Kahuku Elderly Hauoli Hale will monitor the vacancies and waiting lists regularly to ensure that there are enough applicants to fill the vacancies. Furthermore, Kahuku Elderly Hauoli Hale will monitor the waiting list to make sure that they do not become so long that the wait for a unit becomes excessive. The waiting list may be closed for one or more unit sizes when the average wait is excessive. When the waiting list is closed, Kahuku Elderly Hauoli Hale will advise potential applicants that the waiting list is closed and refuse to take additional applications. Kahuku Elderly Hauoli Hale will publish a notice stating that the waiting list is closed in a publication likely to be read by potential applicants. The notice will state the reasons for Kahuku Elderly Hauoli Hale s refusal to accept additional applications. When Kahuku Elderly Hauoli Hale agrees to accept applications again, the notice of this action will be announced in a publication likely to be read by potential applicants in the same manner as the notification that the waiting list was closed. Advertisements will include where and when to apply and will conform to the advertising and outreach activities described in the Affirmative Fair Housing Marketing Plan for Kahuku Elderly Hauoli Hale. KS RSP rev

8 AVAILABILITY OF RESIDENT SELECTION PLAN The Resident Selection Plan shall be posted in a conspicuous and public area at the site. Changes to the Plan will be sent via U.S. mail to all persons on the active Waiting List. When the Waiting List opens, the Resident Selection Plan will be distributed with applications and are available by request from management. ANNUAL/INTERIM RECERTIFICATION REQUIREMENTS All residents must be re-certified annually. Residents are also required to report all interim changes to management that occur between annually scheduled re-certifications. Enterprise Income Verification (EIV) In an effort to ensure the right assistance is provided to the right people, The Department of Housing and Urban Development (HUD) has provided property managers with access to a verification database called the Enterprise Income Verification System (EIV). Kahuku Elderly Hauoli Hale utilizes EIV during the certification process for applicants and residents. All adult applicants and residents must give consent to the release of this information by signing HUD Forms 9887 and 9887A. Kahuku Elderly Hauoli Hale will utilize the EIV Existing Tenant Search at the time applications are processed to determine if household members are currently residing at another Multifamily Housing or Public and Indian Housing (PIH) location. EIV gives Kahuku Elderly Hauoli Hale the option to query both the TRACS and Public and Indian Housing s (PIH s) Information Center (PIC) databases. Nothing prohibits a housing assistance recipient from applying to this property. However, the applicant must move out of the current property and/or forfeit any project-based Section 8 voucher assistance before HUD assistance on this property will begin. If the applicant or a member of the applicant s household is residing at another location, Kahuku Elderly Hauoli Hale will discuss this with the KS RSP rev applicant, giving the applicant the opportunity to explain any circumstances relative to the applicant being assisted at another location. Depending on the outcome of the discussion, Kahuku Elderly Hauoli Hale may need to follow-up with the respective PHA or O/A to confirm the individual s program participation status before admission. The Existing Tenant Search report gives Kahuku Elderly Hauoli Hale the ability to coordinate move-out and move-in dates with the PHA or O/A of the property at the other location. If the applicant or any member of the applicant household fails to fully and accurately disclose rental history, the application may be denied based on the applicant s misrepresentation of information. PETS Residents are permitted to keep common household pets in the dwelling unit (subject to the provisions in 24 CFR Part 243 and the pet policy promulgated under 24 CFR Section ). SERVICE or ASSISTANCE animals are not considered pets and are not required to comply with the provisions of the Pet Policy. Service or Assistance animals are those animals specifically required to assist individuals with documented disabilities. Please notify Management if you require a Service or Assistance animal. EQUAL HOUSING OPPORTUNITY EAH is an Equal Opportunity Housing Provider. EAH does not discriminate on the basis of handicapped status in the admission or access to, or treatment or employment in, its federally-assisted programs and activities. EAH, INC. A NONPROFIT HOUSING CORPORATION Creating community by developing, managing and promoting quality affordable housing. 8

9 HUD FY 2012 Income Limits Effective December 1, % of Median (Very Low Income) 1 Person Household 36,050 2 Person Household 41,200 3 Person Household 46,350 KS RSP rev

10 TIME & DATE OF APPLICATION Application for Housing KAHUKU ELDERLY HAUOLI HALE PUULUANA PLACE #100 KAHUKU, HI TELEPHONE (808) FAX (808) EAH Housing Use Only APPLICATION APPROVED: Yes No APPLICATION RECEIVED BY: APPLICATION #: APPLICATION REVIEWED BY: BARRIER FREE (H/C) UNIT REQUESTED? YES NO LOTTERY #: Please complete the following application with legible print and return it to the Property. All Items must be complete in order to determine your eligibility. If an item does not apply to you, please check N/A next to the question. EAH does not discriminate on the basis of race, color, sex, age, religion, origin, family or marital status, disability, or sexual orientation. Number of bedrooms requested: 1 BR 2BR 1 st Request: 2 nd Request: A. GENERAL INFORMATION: HEAD OF HOUSEHOLD CO-HEAD Check if N/A Name: Home Phone: Cell Phone Work Phone: Name: Home Phone: Cell Phone Work Phone: B. HOUSEHOLD COMPOSITION List all persons, including yourself, who will be living in the apartment. List the head of your household first. Do not include minors who will reside in the unit less than 50% of the time. Full Time Name Relationship DOB Age Social Security/TIN Student Y/N First/Last To HEAD (mm/dd/yy) (optional) (K-12/College) 1. HEAD 2. CO-HEAD/SPOUSE Limited English Proficiency (LEP) Requirement: What is the primary language spoken in your household? 2. YES NO Where there any changes to your household within the last 12 months? If yes, please explain giving name and relationship: 3. YES NO 4. YES NO N/A 5. YES NO Do you expect any changes to your household within the next 12 months? If yes, please explain giving name and relationship: Do you have primary physical custody of all minors (50% or more of the time) listed under the Household Composition above? If no, please explain: Do you have a Section 8 Voucher through the Housing Authority? If yes where? Section 8 Voucher number Page 1

11 6. YES NO 7. YES NO 8. YES NO 9. YES NO Do you have a physician s statement that would require you to have an accessible unit? (Design Features for persons with disabilities). If yes, please explain: If there are no handicap units available, are you still interested in renting another apartment that is not handicap-accessible? Are there any absent household members that are not listed under the Household Composition above? If yes, please explain giving name and relationship? Will you or anyone in your household require a live-in care attendant? Name of Live-in Care Attendant: Relationship if any: 10. YES NO Will you take an apartment when one is available? C. STUDENT STATUS 1. YES NO Does your household consist of all persons who are full-time students (Examples: College/University, trade school, etc.)? 2. YES NO Does your household consist of all persons who have been a full-time student in the previous 5 months? 3. YES NO Does your household anticipate becoming an all full-time student household in the next 12 months? If you answered YES to any of the previous three questions are you: 4. YES NO Receiving assistance under Title IV of the Social Security Act (AFDC/TANF)? 5. YES NO Enrolled in a job training program receiving assistance through the Job Training Participation Act (JTPA) or other similar program? 6. YES NO Married and filing (or are entitled to file) a joint tax return? 7. YES NO Single parent with a dependent child or children and neither you nor your child(ren) are dependent on another individual? 8. YES NO Previously enrolled in the Foster Care program (age 18-24)? D. CITIZENSHIP 1. YES NO Are you a U.S. Citizen? 2. YES NO If no, are you a Non-Citizen with eligible immigration status? E. RACE AND ETHNICITY The information regarding race and ethnicity solicited on this application is requested in order to assure the Federal Government that EAH Inc. complies with the Federal laws prohibiting discrimination against applicants on the basis of race and ethnicity. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in anyway. Household Member Name Ethnicity Race (check one or more) 1. Hispanic or Latino American Indian/Alaskan Native White Asian Non-Hispanic or Latino Black or African American Native Hawaiian or Pacific Islander 2. Hispanic or Latino American Indian/Alaskan Native White Asian Non-Hispanic or Latino Black or African American Native Hawaiian or Pacific Islander 3. Non-Hispanic or Latino American Indian/Alaskan Native White Asian Non-Hispanic or Latino Black or African American Native Hawaiian or Pacific Islander 4. Hispanic or Latino American Indian/Alaskan Native White Asian Non-Hispanic or Latino Black or African American Native Hawaiian or Pacific Islander 5. Non-Hispanic or Latino Non-Hispanic or Latino American Indian/Alaskan Native White Asian Black or African American Native Hawaiian or Pacific Islander Page 2

12 F. INCOME Employment Check if N/A Please provide the following employment information for each household member. Household Member Name (List the name of the recipient) Employment Amount Employer: Contact Name: Position Held: Contact Phone: How long employed: Contact Fax: Employment Amount Employer: Contact Name: Position Held: Contact Phone: How long employed: Contact Fax: Employment Amount Employer: Contact Name: Position Held Contact Phone: How long employed: Contact Fax: Employment Amount Employer: Contact Name: Position Held Contact Phone: How long employed: Contact Fax: Employment Amount Employer: Position Held How long employed: Contact Name: Contact Phone: Contact Fax: Gross Monthly Amount TOTAL GROSS MONTHLY INCOME (Add the monthly amounts listed above) TOTAL GROSS ANNUAL INCOME (Gross monthly amounts listed above x 12) Do you anticipate any changes in this income in the next 12 months? YES NO If yes, please list family member and explain: TOTAL GROSS ANNUAL INCOME FROM PREVIOUS YEAR Is any member of your household legally entitled to receive income assistance? YES NO Is any member of your household likely to receive income or assistance (monetary or not) from someone who is not a member of your household? YES NO If yes, please explain: Is the income received? YES NO Other Sources of Income Check if N/A List all money earned or received by everyone living in your household. This includes money received from the categories listed below and from DISABILITY PAYMENTS or DEATH BENEFITS, WORKERS COMPENSATION, ANNUITIES, PERIODIC PAYMENTS from INSURANCE POLICIES and OTHER SOURCES including PERIODIC LOTTERY PAYMENTS. LIST GROSS MONTHLY AMOUNTS RECEIVED BELOW. If a section doesn t apply, cross it out or write N/A. Household Member Name (List the name of the recipient) Source of Income Gross Monthly Amount Page 3

13 Social Security Social Security SSI Benefits SSI Benefits Pension (list source) Address: City, State, Zip: Pension (list source) Address: City, State, Zip: Pension (list source) Address: City, State, Zip: Veteran s Benefits (provide claim #) Unemployment Compensation Unemployment Compensation Title IV/TANF (Welfare) Contributions to your Household (monetary or not) Full-Time Student Income (18 & over only) Full-Time Student Income (18 & over only) Financial Aid (grants & scholarships exceeding the amount of tuition may have to be included in total income) Interest Income (source) Interest Income (source) Long Term Medical Care Insurance Payments in excess of 180/day Scheduled payments from Investments Alimony Are you entitled to receive alimony? YES NO If yes, list the amount you are entitled to receive. Do you receive alimony? YES NO If yes, list amount you receive. Child Support Are you entitled to receive child support? YES NO If yes, list the amount you are entitled to receive. Do you receive child support? YES NO Page 4

14 If yes, list the amount you receive. Other Income Other Income Other Income Do you anticipate any changes in this income in the next 12 months? YES NO If yes, please list family member and explain: G. ASSETS Have you ever filed Bankruptcy? YES NO If yes, please describe below: If your assets are too numerous to list here, please request an additional form. If a section doesn t apply, cross out or write NA. Checking Accounts Check if N/A Family Member First Name Account # Name of Bank/Financial Institution Balance Savings Accounts Check if N/A Family Member First Name Account # Name of Bank/Financial Institution Balance Trust Accounts Check if N/A Family Member Name Account # Name of Bank/Financial Institution Balance Certificates of Deposit Check if N/A Family Member Name Account # Name of Bank/Financial Institution Balance Page 5

15 Savings Bonds Check if N/A Family Member Name Account Type Maturity date Value Life Insurance Policies Check if N/A Family Member Name Account Type Maturity date Cash Value Mutual Funds Check if N/A Family Member Name Name # Shares Interest/Dividend Value Stocks Check if N/A Family Member Name Name # Shares Dividend Paid Value Bonds Check if N/A Family Member Name Name # Shares Interest/Dividend Value Investment Property Check if N/A Family Member Name Description Appraised Value Other Assets/Accounts Check if N/A Please list any of the following assets that apply to you: MONEY MARKET FUND, TREASURY BILLS, IRA OR KEOGH, RETIREMENT, 401K/PENSION FUNDS, INHERITANCE, LOTTERY WINNINGS, INSURANCE SETTLEMENTS, CAPITAL GAINS, CAPITAL INVESTMENTS, OR PERSONAL PROPERTY HELD AS AN INVESTMENT. ALSO INCLUDE ALL ASSETS THAT MAY BE HELD JOINTLY WITH ANOTHER PERSON. Page 6

16 Family Member First Name Asset/Account Type Name of Bank/Financial Institution Value H. REAL ESTATE /DISPOSED OF ASSETS Do you own real property? YES NO (Includes land, houses, real estate, in the USA or any other country) If Yes answer the questions below: Family Member Name Property Type Property Address/City/State Market Value Mortgage or Outstanding Loans Balance Due Amount of Annual Insurance Premium Amount of Most Recent Tax Bill Does any member of your household have an asset(s) owned jointly with a person who is NOT a member of your household? YES NO If yes, please describe: Do they have access to the asset(s)? YES NO Have you sold any Real Estate OR disposed of any assets for less than Fair Market Value (FMV) in the last 2 years? (e.g. cash, property, bank accounts) YES NO If Yes answer the questions below: Family Member Name Type of Real Estate or Asset Fair Market Value when Sold/Disposed Amount Sold/Disposed For Date of Transaction (month, day, and year) Have you disposed of any other assets in the last 2 years? (e.g. given away money to relatives, set up Irrevocable Trust Accounts)? YES NO If Yes answer the questions below: Describe the Asset Date of Disposition (month, day, and year) Amount Disposed For Do you have any other assets not listed above (excluding personal property)? YES NO If yes, please list: I. ALLOWANCES Page 7

17 1. YES NO Do you pay any out-of-pocket childcare expenses? If yes how much do you pay per month? 2. YES NO Is there any household member (18 and over) that is a full time student? If yes, please list below: Family Member Name Name of School Attending Address of School 3. YES NO 4. YES NO 5. YES NO 6. YES NO 7. YES NO 8. YES NO Are you covered by any medical insurance? If yes how much are your monthly premiums? Medicare Med-QUEST Blue Cross/Shield Kaiser AARP Other Do you or any member have any prescription drug expenses not covered by insurance? If yes, how much do you anticipate paying out-of-pocket per month? Do you have any anticipated medical expenses that are NOT covered by insurance? If yes, how much per month? Do you anticipate any major dental, vision, or hearing-aid expenses in the coming year that are not covered by insurance? If yes, how much do you anticipate spending out-of-pocket next year? If you or your co-head or spouse is employed, do you anticipate expenses in the COMING year for the cost of a care attendant for you or your spouse as a handicapped or disabled person as defined by HUD? (If yes, proof of actual expenses are required) If yes, how much do you anticipate out-ofpocket per month? Do you or any member have any prescription drug expenses not covered by insurance? If yes, how much do you anticipate paying out-of-pocket per month? J. HOUSING LANDLORD REFERENCE HEAD OF HOUSEHOLD Name Current Address City/Zip Code Please complete all areas below, giving the last 2 consecutive years of housing history. CO-HEAD/Other (If different from HEAD) Check if N/A Name Current Address City/Zip Code Own Rent Other Own Rent Other Amount Paid Monthly Amount Paid Monthly Length of time Lived there From to Length of time Lived there From Name of Landlord: Name of Landlord: to Address of Landlord: City/Zip Code of Landlord: Phone Number of Landlord: Address of Landlord: City/Zip Code of Landlord: Phone Number of Landlord: Additional information if required: First Previous Address Check if N/A Please provide information if current Landlord reference is less than 2 years. HEAD OF HOUSEHOLD CO-HEAD/Other (If different from HEAD) Check if N/A Name Name 1 st Previous Address 1 st Previous Address Page 8

18 City/Zip Code City/Zip Code Own Rent Other Own Rent Other Amount Paid Monthly Amount Paid Monthly Length of time Lived there From to Length of time Lived there From Name of Landlord: Name of Landlord: to City/Zip Code of Landlord: Phone Number of Landlord: City/Zip Code of Landlord: Phone Number of Landlord: Additional information if required: Second Previous Address HEAD OF HOUSEHOLD Name Check if N/A CO-HEAD/Other (If different from HEAD) Check if N/A Name 2 nd Previous Address 2 nd Previous Address City/Zip Code City/Zip Code Own Rent Other Own Rent Other Amount Paid Monthly Amount Paid Monthly Length of time Lived there From to Length of time Lived there From Name of Landlord: Name of Landlord: to Address of Landlord: City/Zip Code of Landlord: Phone Number of Landlord: Address of Landlord: City/Zip Code of Landlord: Phone Number of Landlord: 1. YES NO Have you ever been evicted in the past 5 years? If yes, please explain: 2. YES NO Have you willfully or intentionally ever refused to pay rent? K. VEHICLE INFORMATION Check if N/A Household Member Name HI Driver ID Car Make/Model License Plate Color Year Page 9

19 L. CRIMINAL BACKGROUND 1. YES NO 2. YES NO 3. YES NO 4. YES NO 5. YES NO Have YOU or ANY MEMBER of your household been convicted of any fraud in a federally assisted housing program or been requested to repay for misrepresenting information for such housing program? Has assistance/subsidy/tenancy ever been terminated for fraud, non-payment of rent, or failure to cooperate with recertification procedures? Have YOU or ANY MEMBER of your household ever been convicted of a felony or pled guilty or no contest to a felony whether or not resulting in a conviction? Have YOU or ANY MEMBER of your household ever been convicted of, pled guilty or no contest to, engaging in acts of violence or threats of violence, including, but no limited to, unlawful activity involving weapons or ammunition, whether or not resulting in a conviction? Have YOU or ANY MEMBER of your household ever been convicted of, pled guilty or no contest to, engaging in the illegal manufacture, sale, distribution, use, or possession of an illegal drug or controlled substance whether or not resulting in a conviction? 6. YES NO 7. YES NO Have YOU or ANY MEMBER of your household ever been convicted of pled guilty or no contest to, a criminal complaint involving sexual misconduct, whether or not resulting in a conviction? Are YOU or ANY MEMBER of your household subject to a lifetime sex offender registration requirement in ANY state? (Please note you will be given the opportunity to remove the ineligible household member. If you refuse to remove the ineligible household member, the application must be denied) IF you answered YES to any questions listed above in the Criminal Background Section of this application, Please provide an explanation below. Include the date, circumstances, and nature of the offenses: M. HUD SECTION 236 PROGRAM - REQUIRED HUD REGULATORY PREFERENCES Page 10

20 (a) This Property receives subsidy under the Section 236 Program and remains subject to regulatory oversight under the Section 236 Program. Kukui Tower shall apply preferences in determining the order of an applicant s placement on the Waiting List for a basic rent unit assisted under the Section 236 Program. Pursuant to 24 CFR Part 236 and HUD Handbook REV-1, preference shall be provided to applicants displaced as a result of: (i) government action, or (ii) a Presidentially-declared disaster. (b) In addition to the above, the Property is also receiving Rental Assistance Payments so secondary preferences shall apply (in descending order of priority) as follows: (i) Applicants eligible for Rental Assistance Payments; (ii) Applicants eligible to pay less than the Section 236 market rent approved for the Property; and (iii) Applicants with income sufficient to pay the Section 236 market rent approved for the Property. For purposes of this subsection, the Section 236 market rent shall be the market rent as it appears on the most recently approved Section 236 Rent Schedule for the Property. Documentation or sources of information required to verify an Applicant s qualification for a preference under this Section shall be determined by HUD. CHECK AS APPLICABLE: 1. I/we have been displaced by a government action 2. I/we have been displaced by a Presidentially-declared disaster 3. I/we are eligible for Rental Assistance Payments 4. I/we are eligible to pay less than the Section 236 market rent approved for the Development 5. I/we have income sufficient to pay the Section 236 market rent approved for the Development Use this space if needed for answering questions if you have ran out of space in that section (enter the section letter and number of the question) Section Number Answer Page 11

21 N. CERTIFICATION AND RELEASE OF INFORMATION I/We hereby certify that I/we do not and will not maintain a separate, subsidized rental unit in another location. I/we understand that I/we must pay a security deposit prior to occupancy. I/we certify that the housing I/we occupy will be my/our only residence. I/We understand that eligibility for housing will be based on applicable sections of the HUD Occupancy Handbook and EAH Housing s Resident Selection Plan. I/We understand that this application in no way ensures occupancy and that my/our application can be rejected based on, but not limited to, poor credit or landlord references, police records indicating unacceptable or criminal behavior. All information supplied here or elsewhere will be used to determine my household s eligibility for housing. I further understand that providing any false, fraudulent, misleading, or incomplete information can cause a delay in processing and may be grounds for denial of tenancy; or in the event that I become a resident, or I am an existing resident, would be considered a material breach of my rental agreement and can be used as grounds to immediately terminate my tenancy. Any yes response on the criminal activity questionnaire section of this application may lead to rejection of my application. I declare that all information and answers supplied during the application process by me, or on my behalf, including but not limited to, the answers to the above-noted questions, are true and correct. I understand that falsification of information found before or after acceptance of this Property includes penalties that will result in cancellation of my application, also to include eviction, loss of assistance, if applicable. As a HUD subsidized property additional fines are imposed: fines of 10, and five year s imprisonment. 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. O. RELEASE OF INFORMATION I/We do hereby authorize EAH, Inc. (the Managing Agent) and/or the property owner to obtain information or materials deemed necessary to determine my/our eligibility for housing. I/we authorize EAH, Inc. and/or the property owner to verify my/our past and present employment earnings records, bank accounts, stock holdings, and any other assets needed to process my/our rental application. I/we further authorize EAH, Inc. and/or the property owner to order a consumer credit report and verify other credit information. I/we hereby give my/our permission for EAH, Inc. and/or the property owner to verify the information provided above, including but not limited to criminal background screening. Head Of Household: Printed Name Signature Date Spouse/Co-Head: Printed Name Signature Date Other Adult: Printed Name Signature Date Other Adult: Printed Name Signature Date Page 12

22 Other Adult: Printed Name Signature Date Management: Signature Date THE FILING OF THIS APPLICATION IN NO WAY GUARANTEES YOU AN APARTMENT. PLEASE DO NOT MAIL MORE THAN ONE APPLICATION PER HOUSEHOLD. IF MORE THAN ONE APPLICATION IS RECEIVED, APPLICATIONS WILL BE PLACED AT THE END OF THE WAITING LIST. Revision Date: May 1, 2013 Combo236 Page 13