Mod Rehab Annual Review forms packet

Transcription

1 Md Rehab Annual Review frms packet Indicates frms included in the Md Rehab Annual Review frms packet. Agencies r applicants supply the ther materials listed. SRO Persnal Declaratin SHA Release f Infrmatin HUD Authrizatin fr the Release f Infrmatin Citizenship, MR Declaratin Citizenship, Verificatin Cnsent Zer Incme Affidavit (if applicable) In additin t the abve dcuments, please submit the fllwing if applicable: Emplyment Verificatin (if currently wrking) Verificatin f End f Emplyment (if within previus six mnths) Self-Emplyment Frm (including mst recent Tax Return) Participant Training Incme Verificatin frm Verificatin f Veteran s Benefits Verificatin f Pensin r Retirement Benefits Verificatin f Assets (if ver 5,000) Verificatin f Out-f-Pcket Medical Expenses Fax these dcuments t (206) 6- D nt fax this page! Frms must be signed by all husehld members 18 years f age r lder. MR_Annual_Review_packet_cver_1107

2 *136* SRO PERSONAL DECLARATION Seattle Husing Authrity 190 Queen Anne Ave N Seattle, WA YOU MUST ANSWER EVERY QUESTION ON THIS FORM AND YOU MUST SIGN TO CERTIFY THAT THE INFORMATION YOU PROVIDE IS COMPLETE AND ACCURATE. (Attached is HUD-9886, Authrizatin t Release Infrmatin and the Federal Privacy Act) Family Member s Legal Name Relatinship f Birth Scial Security Number Head Street Address Hme Phne Message Phne TOTAL HOUSEHOLD INCOME (See the enclsed sheet What t Submit fr types f incme.) List all mney yu received within the last sixty (60) days. Include any mney yu earned and any mney given t yu. Yu must als reprt if yu expect a change in the amunt f yur incme r the surce f yur incme. Emplyer s Name Address Phne Number Ttal Wages per week/mnth/year Scial Security Benefits per mnth Public Assistance: GAU per mnth Unemplyment Benefits per mnth All ther incme: VA Benefits, Pensins, Insurance Payments, Trust Funds, etc. per mnth r year per mnth r year Des anyne utside f yur husehld pay fr any f yur bills r give yu any mney? If yes, please explain: NO YES TOTAL HOUSEHOLD ASSETS Including bank accunts & investments (CDs, stcks, bnds, IRAs) Des yur husehld have interest bearing financial assets with a cmbined ttal value f 5,000 r mre? NO YES If yes, then fill ut belw Type f Asset Current Value Current Interest Rate Checking % Savings % % Name f Asset (Bank name, etc) Address Describe any ther assets yu may have (cars, prperty, etc.): I UNDERSTAND AND AGREE THAT THE ABOVE INFORMATION WILL BE VERIFIED FROM THE SOURCE(s). I certify under penalty f perjury that I have cmpleted all f the abve infrmatin t the best f my knwledge and that it is true and crrect. I als understand that any change f husehld members must be reprted in writing t the Seattle Husing Authrity within ten (10) days f the change. SIGNATURE HEAD OF HOUSEHOLD DATE 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.

3 *277* PROJECT BASED AND MODERATE REHABILITATION RELEASE OF INFORMATION Applicant Name (Print Clearly): Scial Security #: I hereby authrize the Seattle Husing Authrity t request and btain infrmatin in the categries listed belw, fr the purpse f determining my eligibility t receive husing assistance, and my suitability t be an SHA resident. I als authrize the persns, businesses, and rganizatins t which such requests are directed, t prvide the infrmatin requested by SHA, and I indemnify them frm any harm fr prviding infrmatin in accrdance with such requests. I understand that I will be given the pprtunity t cntest any negative determinatins based n the infrmatin btained. I agree that cpies f this dcument may be made t authrize inquiries frm surces I have given t SHA, r frm ther surces which becme apparent frm infrmatin cllected during the cmpletin f my applicatin file. I als authrize SHA and the wner and/r manager f the building in which I reside t share financial and scial infrmatin fr the purpses f verifying my cntinued eligibility and suitability fr public husing. This cnsent expires 15 mnths after signed. Infrmatin necessary t authenticate preference claims Rental histry recrds, including but nt limited t infrmatin abut the ability t pay rent, take care f rental prperty, and get alng well with neighbrs Residential histry references, including but nt limited t infrmatin abut the ability t live independently, care fr prperty, and get alng well with thers Nn-residential references frm individuals with whm a prfessinal relatinship has been established, and references frm neighbrs, cmmunity, and relatives References frm emplyers, including wage and salary infrmatin, and jb perfrmance Criminal histry, including fingerprint submissin where necessary t effect psitive identificatin Services prvided by individuals r agencies which are relevant t the ability t pay rent, take care f rental prperty, and get alng well with neighbrs and cmmunity Incme and asset infrmatin frm all surces, fr all family members Schl registratin fr minr children, and fr family members ver the age f 18 where required t establish prgram eligibility Registratin in educatinal r vcatinal training prgrams including infrmatin abut participatin, prgress, and cmpletin f such prgrams Verificatin f disability r handicap, if necessary fr prgram eligibility (nt including details f actual disability r handicap) Verificatin f need fr reasnable accmmdatin, if requested Credit reprts and/r tenant screening reprts frm private screening cntractrs Outstanding debts t ther husing agencies X SIGNATURES: X Head f Husehld C-Head, Spuse, Dmestic Partner, Other Adult DATE X X Other Adult Other Adult DATE

4 *137* Authrizatin fr the Release f Infrmatin / Privacy Act Ntice Tenant ID: U.S. Department f Husing and Urban Develpment PHA requesting release f infrmatin; (Crss ut space if nne) (Full address, name f cntact persn, and date) IHA requesting release f infrmatin: (Crss ut space if nne) (Full address, name f cntact persn, and date) Authrity: Sectin 904 f the Stewart B. McKinney Hmeless Assistance Amendments Act f 1988, as amended by Sectin 903 f the Husing and Cmmunity Develpment Act f 1992 and Sectin 3003 f the Omnibus Budget Recnciliatin Act f This law is fund at 42 U.S.C This law requires that yu sign a cnsent frm authrizing: (1) HUD and the Husing Agency/Authrity (HA) t request verificatin f salary and wages frm current r previus emplyers; (2) HUD and the HA t request wage and unemplyment cmpensatin claim infrmatin frm the state agency respnsible fr keeping that infrmatin; (3) HUD t request certain tax return infrmatin frm the U.S. Scial Security Administratin and the U.S. Internal Revenue Service. The law als requires independent verificatin f incme infrmatin. Therefre, HUD r the HA may request infrmatin frm financial institutins t verify yur eligibility and level f benefits. Purpse: In signing this cnsent frm, yu are authrizing HUD and the abve-named HA t request incme infrmatin frm the surces listed n the frm. HUD and the HA need this infrmatin t verify yur husehld s incme, in rder t ensure that yu are eligible fr assisted husing benefits and that these benefits are set at the crrect level. HUD and the HA may participate in cmputer matching prgrams with these surces in rder t verify yur eligibility and level f benefits. Uses f Infrmatin t be Obtained: HUD is required t prtect the incme infrmatin it btains in accrdance with the Privacy Act f 1974, 5 U.S.C. 552a. HUD may disclse infrmatin (ther than tax return infrmatin) fr certain rutine uses, such as t ther gvernment agencies fr law enfrcement purpses, t Federal agencies fr emplyment suitability purpses and t HAs fr the purpse f determining husing assistance. The HA is als required t prtect the incme infrmatin it btains in accrdance with any applicable State privacy law. HUD and HA emplyees may be subject t penalties fr unauthrized disclsures r imprper uses f the incme infrmatin that is btained based n the cnsent frm. Private wners may nt request r receive infrmatin authrized by this frm. Wh Must Sign the Cnsent Frm: Each member f yur husehld wh is 18 years f age r lder must sign the cnsent frm. Additinal signatures must be btained frm new adult members jining the husehld r whenever members f the husehld becme 18 years f age. Persns wh apply fr r receive assistance under the fllwing prgrams are required t sign this cnsent frm: PHA-wned rental public husing Turnkey III Hmewnership Opprtunities Mutual Help Hmewnership Opprtunity Sectin 23 and 19(c) leased husing Sectin 23 Husing Assistance Payments HA-wned rental Indian husing Sectin 8 Rental Certificate Sectin 8 Rental Vucher Sectin 8 Mderate Rehabilitatin Failure t Sign Cnsent Frm: Yur failure t sign the cnsent frm may result in the denial f eligibility r terminatin f assisted husing benefits, r bth. Denial f eligibility r terminatin f benefits is subject t the HA s grievance prcedures and Sectin 8 infrmal hearing prcedures. Surces f Infrmatin T Be Obtained State Wage Infrmatin Cllectin Agencies. (This cnsent is limited t wages and unemplyment cmpensatin I have received during perid(s) within the last 5 years when I have received assisted husing benefits.) U.S. Scial Security Administratin (HUD nly) (This cnsent islimited t the wage and self emplyment infrmatin and payments f retirement incme as referenced at Sectin 6103(l)(7)(A) f the Internal Revenue Cde.) U.S. Internal Revenue Service (HUD nly) (This cnsent is limited t unearned incme [i.e., interest and dividends].) Infrmatin may als be btained directly frm: (a) current and frmer emplyers cncerning salary and wages and (b) financial institutins cncerning unearned incme (i.e., interest and dividends). I understand that incme infrmatin btained frm these surces will be used t verify infrmatin that I prvide in determining eligibility fr assisted husing prgrams and the level f benefits. Therefre, this cnsent frm nly authrizes release directly frm emplyers and financial institutins f infrmatin regarding any perid(s) within the last 5 years when I have received assisted husing benefits. Original is retained by the requesting rganizatin. ref. Handbks , , & frm HUD-9886 (7/94)

5 Cnsent: I cnsent t allw HUD r the HA t request and btain incme infrmatin frm the surces listed n this frm fr the purpse f verifying my eligibility and level f benefits under HUD s assisted husing prgrams. I understand that HAs that receive incme infrmatin under this cnsent frm cannt use it t deny, reduce r terminate assistance withut first independently verifying what the amunt was, whether I actually had access t the funds and when the funds were received. In additin, I must be given an pprtunity t cntest thse determinatins. This cnsent frm expires 15 mnths after signed. Signatures: Head f Husehld Scial Security Number (if any) f Head f Husehld Other Family Member ver age 18 Spuse Other Family Member ver age 18 Other Family Member ver age 18 Other Family Member ver age 18 Other Family Member ver age 18 Other Family Member ver age 18 Privacy Act Ntice. Authrity: The Department f Husing and Urban Develpment (HUD) is authrized t cllect this infrmatin by the U.S. Husing Act f 1937 (42 U.S.C et. seq.), Title VI f the Civil Rights Act f 1964 (42 U.S.C. 2000d), and by the Fair Husing Act (42 U.S.C ). The Husing and Cmmunity Develpment Act f 1987 (42 U.S.C. 3543) requires applicants and participants t submit the Scial Security Number f each husehld member wh is six years ld r lder. Purpse: Yur incme and ther infrmatin are being cllected by HUD t determine yur eligibility, the apprpriate bedrm size, and the amunt yur family will pay tward rent and utilities. Other Uses: HUD uses yur family incme and ther infrmatin t assist in managing and mnitring HUD-assisted husing prgrams, t prtect the Gvernment s financial interest, and t verify the accuracy f the infrmatin yu prvide. This infrmatin may be released t apprpriate Federal, State, and lcal agencies, when relevant, and t civil, criminal, r regulatry investigatrs and prsecutrs. Hwever, the infrmatin will nt be therwise disclsed r released utside f HUD, except as permitted r required by law. Penalty: Yu must prvide all f the infrmatin requested by the HA, including all Scial Security Numbers yu, and all ther husehld members age six years and lder, have and use. Giving the Scial Security Numbers f all husehld members six years f age and lder is mandatry, and nt prviding the Scial Security Numbers will affect yur eligibility. Failure t prvide any f the requested infrmatin may result in a delay r rejectin f yur eligibility apprval. Penalties fr Misusing this Cnsent: HUD, the HA and any wner (r any emplyee f HUD, the HA r the wner) may be subject t penalties fr unauthrized disclsures r imprper uses f infrmatin cllected based n the cnsent frm. Use f the infrmatin cllected based n the frm HUD 9886 is restricted t the purpses cited n the frm HUD Any persn wh knwingly r willfully requests, btains r disclses any infrmatin under false pretenses cncerning an applicant r participant may be subject t a misdemeanr and fined nt mre than 5,000. Any applicant r participant affected by negligent disclsure f infrmatin may bring civil actin fr damages, and seek ther relief, as may be apprpriate, against the fficer r emplyee f HUD, the HA r the wner respnsible fr the unauthrized disclsure r imprper use. Original is retained by the requesting rganizatin. ref. Handbks , , & frm HUD-9886 (7/94)

6 SHA-1117 Seattle Husing Authrity Revised (10/01) Manual Ref. L *132* MOD REHAB DECLARATION OF CITIZENSHIP OR IMMIGRATION STATUS NOTICE Yu Only Need t Declare Citizenship r Status Once If yu r yur husehld members have nt declared citizenship r eligible immigratin status, yu will nly need t sign this frm nce. Husehld members wh signed this frm DO NOT need t sign it again, as lng as a cpy f the declaratin is in the resident file. Sectin 214 f the Husing and Cmmunity Develpment Act f 1980, as amended, requires the Seattle Husing Authrity (SHA) and the Department f Husing & Urban Develpment (HUD) t ensure that financial assistance is made available nly t persns wh are U.S. Citizens, U.S. Natinals r Nn-citizens wh have been lawfully admitted t the United States and cnsidered t have eligible immigratin status. (Fr details, see Hw Yur Immigratin Status Can Affect Yur Husing Assistance. ) All adults (18 years and lder) wh currently live in the husehld must claim their status and sign belw. The head f husehld and/r respnsible adult is als required t certify the status f each minr child wh is currently living in the husehld. All Nn-citizens with Eligible Immigratin Status are required t sign the Verificatin Cnsent Frm and prvide a cpy f their INS dcument(s) fr each member in the husehld. (The nly exceptin t this rule is if a current tenant is 62 years f age r lder and was receiving husing assistance as f June 19, 1995.) 1. Under penalty f perjury, I declare that I am: Adult members (18 yrs. and lder) My Scial Security # is: A Citizen f the United States A Nn-Citizen with Eligible Immigratin Status (please cmplete the fllwing) Head f Husehld (print clearly) Birthdate Alien Registratin # Scial Security # INS Status Cnfirmed: Yes N Cnfirmatin # By Nt able t certify that I am a U.S. Citizen r a Nn-Citizen with Eligible Immigratin Status. Signature 2. Under penalty f perjury, I declare that I am: A Citizen f the United States A Nn-Citizen with Eligible Immigratin Status (please cmplete the fllwing) Spuse/C-Tenant/Other Adult (print clearly) Birthdate Alien Registratin # Scial Security # INS Status Cnfirmed: Yes N Cnfirmatin # By Nt able t certify that I am a U.S. Citizen r a Nn-Citizen with Eligible Immigratin Status. Signature 3. Under penalty f perjury, I declare that I am: Other Adult Name (print clearly) A Citizen f the United States A Nn-Citizen with Eligible Immigratin Status (please cmplete the fllwing) Birthdate Alien Registratin # Scial Security # INS Status Cnfirmed: Yes N Cnfirmatin # By Nt able t certify that I am a U.S. Citizen r a Nn-Citizen with Eligible Immigratin Status. Signature

7 SHA-1118 Seattle Husing Authrity Revised (10/01) Manual Ref. L *132* ELIGIBLE IMMIGRATION STATUS Verificatin Cnsent Frm Sectin 214 f the Husing and Cmmunity Develpment Act f 1980, as amended, requires the Seattle Husing Authrity (SHA) and the Department f Husing & Urban Develpment (HUD) t ensure the financial assistance is made available nly t persns wh are U.S. Citizens, U.S. Natinals r Nn-citizens wh have been lawfully admitted t the United States and cnsidered t have eligible immigratin status. The law requires all tenants fr assisted husing wh claim t have eligible immigratin status t sign a cnsent frm authrizing SHA and HUD t verify the infrmatin supplied with the U.S. Department f Immigratin and Naturalizatin Services (INS). Purpse: This infrmatin is required t determine yur eligibility fr cntinued husing assistance (Federal subsidy). Use f the Infrmatin t be Obtained: The evidence yu supply t dcument yur eligibility fr husing assistance may be released by the Husing Authrity, withut respnsibility fr the further use r transmissin f the evidence by the entity receiving it, (1) HUD, as required by HUD, and (2) the INS fr the purpse f establishing eligibility fr financial assistance and nt fr any ther purpse. Hwever, neither SHA r HUD are respnsible fr the further use r transmissin f the evidence r ther infrmatin by the INS. Wh Must Sign This Cnsent Frm? Each nn-citizen in the husehld wh will be receiving husing assistance and claims eligible immigratin status must sign belw. Adults, age 18 years r lder, must sign fr themselves. In the case f minr children (under 18 years ld), the frm must be signed by the head f husehld and/r adult member wh is respnsible fr each minr child. Failure t Sign the Cnsent Frm: Yur failure t sign the cnsent frm may result in the denial f eligibility r terminatin f assisted husing (subsidy) benefits, r bth. Denial f eligibility r terminatin f benefits (subsidy) is subject t the Husing Authrity s grievance prcedures r Sectin 8 s infrmal hearing prcess, whichever is applicable. Cnsent: I authrize the Husing Authrity f the City f Seattle, r HUD t request and btain verificatin frm the INS f the infrmatin I have supplied regarding my immigratin status. I understand that this infrmatin is true and accurate t the best f my knwledge. Head f Husehld Spuse/C-Tenant Head f Husehld Scial Security Number Other Adult (ver age 18) Other Adult (ver age 18) Other Adult (ver age 18) Other Adult (ver age 18) Cnsent fr Minr Children: I certify that I am the head f husehld and/r the adult family member respnsible fr the minr children listed belw. I authrize the Husing Authrity f the City f Seattle t request and btain verificatin frm the INS f the infrmatin supplied regarding their immigratin status. I understand this infrmatin is needed t determine eligibility fr husing assistance (Federal subsidy); and I certify that the infrmatin I have supplied is true and crrect t the best f my knwledge. List minr children: Signature Parent r Guardian

8 *143* ZERO INCOME AFFIDAVIT I, declare under penalty f perjury that I d nt have any incme. INCOME includes but is nt restricted t: Grss wages, salaries, vertime pay, cmmissins, fees, tips and bnuses Net incme frm peratin f business r frm rental r real persnal prperty Interest, dividends and ther net incme f any kind fr real persnal prperty Peridic payments received frm Scial Security, annuities, insurance plicies, retirement funds, pensins, disability r death benefits and ther similar types f peridic receipts Lump sum payment(s) fr the delayed start f a peridic payment Payments in lieu f earnings, such as unemplyment and disability cmpensatin, wrker s cmpensatin (L & I) and severance pay Public assistance (DSHS/Welfare) Alimny and child supprt payments (whether thrugh the curt system r nt) Regular pay, special pay and allwances f a head f husehld r spuse wh is a member f the Armed Frces (whether r nt living in the dwelling) Regular mnetary gifts frm friends and/r family I understand that I must reprt t Seattle Husing Authrity any change which affects my incme and/r assets. I must reprt the change t Seattle Husing Authrity IN WRITING WITHIN TEN BUSINESS DAYS OF THE CHANGE. I understand that false statements r false infrmatin are grunds fr terminatin f my Sectin 8 participatin. I further understand that false statements r false infrmatin are fraud and punishable under Federal Law. My failure t reprt as required may result in either back charges t the date the incme changed r terminatin f my Sectin 8 participatin. My signature belw certifies that I have read, understd, and agree t cmply with the abve statements. Family Member With Zer Incme Head f Husehld Head f Husehld Scial Security #: cc: Sectin 8 Participant (either in persn, r thrugh the mail with the SHA-581) Rev (12/2002) SHA-129 S8