HOUSING APPLICATION 223 South Winnebago Street Rockford, IL (815)

Transcription

1 HOUSING APPLICATION 223 Suth Winnebag Street Rckfrd, IL (815) APPLICANT NAME The cmplexes listed belw are currently accepting applicatins. Yu must be 18 years f age t apply fr husing. Failure t prperly cmplete this page will delay the prcessing f yur applicatin. Please indicate which prgram yu wuld like t be cnsidered fr by checking the bx(s) belw. Public Husing Prject Based MOD Rehab Elderly/Disabled Public Husing (PH): yur family must meet ccupancy guidelines. Yu may chse nly 2 prperties frm the list: please make yur selectin by placing #1 in frnt f yur first chice and #2 in frnt f yur secnd chice. Public Husing Family Develpments: Public Husing Elderly/Disabled: Blackhawk (1 ~ 4 Bedrms) Ortn Keyes (1 ~ 6 Bedrms) Grman Scattered Sites (2, 3 & 4 Bedrms) Grman Fairgrunds (2 ~ 5 Bedrms) Grman Olesen Plaza (1 & 2 Bedrms) Midvale (1 & 2 Bedrms) Nrth Main (1 & 2 Bedrms) Summit Green (1 & 2 Bedrms) Park Terrace (1 & 2 Bedrms) Buckbee (1 & 2 Bedrms) ******************************************************************************************************** Yur applicatin will be sent t ne f the fllwing upn bedrm size availability. Prject Based Develpments: MOD Rehab Develpments: Mulfrd Park Apartments (2 Bedrms) Capra & Assciates (2 Bedrms) Winnebag Hmes Assciatin (1 ~ 3 Bedrms) Infinity Assets (2 & 3 Bedrms) Anchr VIII (1, 2, & 3 Bedrms) Shelter Care Ministries (1, 2, & 3 Bedrms) Bridge-Rckfrd Alliance (2 & 3 Bedrms) Valley View (1 Bedrm, Elderly/Disabled ONLY) Furman Manr (1 & 2 Bedrms) 23rd St. (3 Bedrms) ELDERLY/DISABLED APTS. FOR 50+YRS. AND/OR PERSONS WITH DISABILITIES T apply fr Jane Addams please visit the nsite management ffice at 505 Seminary St. Rckfrd, IL T apply fr Faust Landmark please visit the nsite management ffice at 630 E. State St. Rckfrd, IL 61104

2 *All prgrams are incme based* ROCKFORD HOUSING AUTHORITY APPLICATION FOR HOUSING THIS IS NOT AN APPLICATION FOR THE SECTION 8 PROGRAM (Be sure t answer all questins cmpletely. Please PRINT legibly) CHANGES TO YOUR FAMILY STATUS, ADDRESS OR QUALIFIED PREFERENCES MUST BE MADE IN WRITING!!! It is the applicant s respnsibility t ntify the Husing Authrity s Applicatin Center f any changes t the infrmatin prvided n this applicatin. Failure t update address and cntact infrmatin may hinder the applicant s ability t be admitted int the prgram. Applicant Last Name First Name MI C-Applicant Last Name First Name MI Current Address Apt # City State Zip Mailing Address (if different frm abve) Hme Phne # Cell # Wrk # Primary language f the applicant: Oral Written Is Head f Huse r Spuse disabled? Yes/N Is there a need fr special accmmdatins? Yes/N Marital Status: ( ) Single ( ) Married ( ) Divrced ( ) Separated ( ) Widw(er) All ther names used: A. HOUSEHOLD COMPOSITION: 1. List everyne, including yurself, fster children/adults, and live-in caretaker wh are necessary fr the care f a family member, wh will be living in the assisted husing unit that yu are applying fr. If yu need mre space cntinue n the back side f this paper. Yu must cmplete each bx fr each family member. Yu (the applicant/head f husehld) are t be in the 1 st line. Last Name First Name MI SSN Relatinship t Head f Husehld Sex M/F Date f Birth Age Place f Birth 1 Applicant/Head f Husehld 2 C-Head D yu anticipate any changes in yur husehld cmpsitin during the next 12-mnths? Yes N. If yes, please explain

3 3. Is any member f yur husehld temprarily away frm the residence? Yes N. If yes, please explain 4. Have yu r anyne in yur husehld ever lived/been assisted in: Public Husing Sectin Eight If yes, what husing authrity? 5. Have yu r anyne in yur husehld used any ther name r Scial Security #? ( ) Yes, please give # ( ) N 6. Have yu r any husehld member ever been arrested r cnvicted f any crime ther than traffic? ( ) Yes ( ) N If yes, please explain: B. PREFERENCE INFORMATION Admissin t the Subsidized Husing prgram is based upn lcal preferences. Please indicate and prvide supprting dcumentatin fr the preference categry(s) that yur husehld falls under. Yu will nt receive the pint(s) until dcumentatin is prvided. Yu must check at least 1 f the fllwing and check all that apply: (Pints will be assigned by prgram criteria). Lcal Preference - Applicant husehld has a permanent physical residence in Winnebag Cunty, IL. Lcal Emplyment Preferences Families whse head spuse r c-head is a resident f r wrks within the City f Rckfrd. Emplyment Preferences Families whse head f husehld is wrking at least 10 hurs a week. Invluntarily Displaced Preference Applies t victims f Natural Disaster that has t be declared by a lcal, state, r federal gvernment entity(fire, fld, earthquake, etc.) Participant is a State r Federal Witness Prtectin Prgram verifiable by lcal, state r federal gvernment entity. Elderly and/r Disabled Preference Elderly preference applies when the head f the husehld, spuse, r c-head is aged 62 r lder. Disabled preference applies t any adult member f the husehld wh is disabled. Hmeless Preference Designated scial service agencies certifies the family is hmeless r prviding a letter frm a hmeless shelter. ARE YOU A PARTICIPANT OF THE CITY OF ROCKFORD CONTINUM OF CARE PROGRAM: Yes N Veteran Preference Applies t applicant that the head f husehld, spuse, r c-head is a current member f the military, a veteran, r the surviving spuse f a veteran. WERE YOU DISCHARGED: Hnrably Dishnrably Near Elderly Applies t persns wh are 50 t 61 years f age that are the head f husehld, spuse, r chead. Educatinal Preference If the head f husehld, spuse, r c-head is currently enrlled in, r a graduate in the last six mnths f a schl training prgram designed t prepare enrllees fr the jb market. WHAT IS THE HIGHEST LEVEL OF EDUCATION YOU COMPLETED. Yur vluntary cperatin in prviding this infrmatin is appreciated. Nne f the Abve

4 C. ESTIMATED INCOME: 1. Based upn all surces f incme fr all members f yur husehld, what is the estimated annual incme fr the husehld? Surces f incme include, but are nt limited t the fllwing: Emplyment, V.A. Benefits, Welfare (TANF, LINK r SNAP, General Relief), Scial Security, SSI, Disability, Unemplyment, Schlarships, Wrker s Cmpensatin, Pensins, Annuity, Child Supprt, Alimny, Fster Care, and earned incme tax credit. This includes any regular cntributins r dnatins t the family frm rganizatins r ther persns wh d nt live in the unit r payments made n behalf f the family by an utside rganizatin/persn(s). Name f Husehld Member Incme Surce Rate($ per day, week, mnth, year) Name f Husehld Member Incme Surce Rate($ per day, week, mnth, year) Bank Accunt: Name f Bank Checking r Savings Check if yu are claiming ZERO incme. Will yu have financial help? Yes N D. RACE/ETHNICITY This fllwing infrmatin is fr statistical purpses nly and will nt affect yur place n the waiting list. Yur vluntary cperatin in prviding this infrmatin is appreciated. Please indicate the ethnicity f the Head f Husehld: Caucasian Hispanic Black Asian/Pac Islander American Indian/Alaskan Native E. REASONABLE ACCOMMODATIONS If yu r a member f yur husehld is mbility impaired, yu may be assigned t an accessible unit at yur request, prviding such a unit is available. There are tw types f accessible units, fully accessible units designed fr wheelchair access and ne stry r flat units. Please indicate if yur family requires an accessible unit and if s, what type. N, I/we d nt require an accessible unit Yes, I/we require an accessible unit (Please indicate belw which type) Fully accessible, thse designed fr wheelchair access One stry r flat units (all the rms are n the grund flr) Hearing r Visually Impaired Other. Please specify

5 F. VAWA The Vilence Against Wmen Reauthrizatin Act f 2013 ( VAWA ) prtects qualified tenants, participants, and applicants, and affiliated individuals, wh are victims f dmestic vilence, dating vilence, sexual assault, r stalking frm being denied husing assistance, evicted, r terminated frm husing assistance based n acts f such vilence against them. APPLICANT CERTIFICATIONS I/We understand that I/we must prvide verificatin that I/we are qualified fr a preference and this must be my/ur status at the time I/we are ffered husing. I further understand that if I/we d nt qualify fr the preference at the time that my/ur husehld is ffered husing, my/ur preference status will be withdrawn and my/ur applicatin returned t the apprpriate place n the waiting list. I/We certify that the statements made n this Applicatin fr Assisted Husing are true t the best f my/ur knwledge and belief and understand that fr verificatin purpses inquiries must be made by the Husing Authrity. I/We authrize emplyer(s), the Department f Public Scial Services, the Scial Security Administratin, and all thers t release any and all infrmatin abut me/us, which the Husing Authrity deems necessary, in rder t be apprved fr participatin in the Husing Prgram. I/We understand that any false r incmplete statements made n this applicatin will cause me/us t be ineligible. I hereby give all this infrmatin willingly. By filling ut this frm either electrnically r manually, I/We give permissin t Rckfrd Husing Authrity t btain a state and natin-wide criminal backgrund check and credit check regarding utstanding debt t any Husing Authrity and/r private r public utility.warning: 18 U.S.C prvides that whever knwingly and willingly makes r uses a dcument r writing cntaining false, fictitius, r fraudulent statement r entry in any manner within the jurisdictin f any department r agency f the United States shall be fined r imprisned fr nt mre than five years r bth. Applicant Signature: Date: C-Applicant Signature: Date: