Caseville Housing Commission

OAKWOOD Senior Citizen Housing 6905 N. Caseville Road Caseville, MI 48725 989.856.3323 Fax 989.856.2552 casevillehousing@comcast.net Caseville Housing Commission Chairperson: Sharon Kelly Commissioners: Melvin Dutcher Grace Cilc Barbara Quinn Erna Farrington Executive Director: Deanne Prutchick For Office Use Only Date and Time Application Was Returned To Office 1. Date 2. Telephone No ( ) 3. Date of Birth Spouse DOB Month Day Year Month Day Year 4. Applicant Name Soc Sec # Last First Middle 5. Spouse Name Soc Sec # Last First Middle 6. Current Address City State Zip How long at current address 7. Are you renting? Name and Address of Landlord 8. Previous Address City State Zip 9. Race Ethnicity 1-White 3-American Indian/Alaska Native 1-Hispanic 2-Black 4-Asian/Pacific Islander 2-Not Hispanic 10. Marital Status: Single Married Separated Divorced Widowed 11. Are you disabled? Yes No Do you require an accessible unit? Yes No 12. Does anyone have legal guardianship, or Power of Attorney over your affairs. Yes No 13. Do you own a pet? Yes No If yes, what kind Breed (Only one pet is allowed) 1/25/00 Revised 6/14/01 5/16/03 2/4/05 1

14. Drivers License # 15. Do You Own An Automobile? Yes No If yes Make Year Color Plate # State 16. Do you have children? Yes No How Many? Please list name & address of each child. 17. Person To Contact In Case Of Emergency: Name ( ) Relationship Address Phone 18. Personal References Please list three complete name & address. NO RELATIVES Name Phone # ( ) Address Name Phone # ( ) Address Name Phone # ( ) Address 19. Are you Employed Yes No If Yes Name of Employer Ph ( ) Address 19. 20. Do you own any firearms? Our Lease requires that all firearms be registered at the office. Please list. 1/25/00 Revised 6/14/01 5/16/03 2

Please complete all applicable information for Tenant, Spouse, or Co-Tenant. Attach an additional sheet if more space is needed. This information is to be completed by the applicant, not by the agency, employer or bank. Income and Expense Information 21. Salary/Wages List gross amount (before deductions) of wages and salaries, overtime pay, commissions, fees, tips, or bonuses per year and indicate source. Wage Wage Source Source 22. Net Income from Business or Profession or Rental of Real or Personal Property Income 23. Social Security/SSI Payments Source $ per month Social Security for $ per month Social Security for $ SSI payment per month for $ SSI payment per month for 24. Pensions: Annuities: Retirement Funds: IRA Accounts $ monthly from $ monthly from $ monthly from 25. All Other Income: - Include income from ALL OTHER SOURCES, such as: Unemployment; Disability Compensation; Workman s Compensation; Severance Pay; Alimony; Child Support; Regular recurring contributions or gifts of money; Educational Grants; Scholarships; VA Benefits; Regular Pay, special pay and allowances for Head of Household in Armed Forces; Public Assistance; AFDC; Welfare or any other source. $ monthly from $ monthly from 1/25/00 Revised 6/14/01 5/16/03 3

26. Medical Expenses: - Include total expenses including medical expenses incurred over the last twelve month period not covered by insurance. May include expenses for; dental; prescription medicine; medical insurance premiums; eyeglasses; hearing aids/batteries; cost of live-in resident assistant; monthly payments required or accumulated major medical bills including that portion of spouse s nursing home care paid from tenant family income. $ annually for $ annually for $ annually for 27. Medicare: $ per month. Asset Information List all information for Tenant, Spouse, Co-Tenant 28. Checking Accounts Account No. Name of Bank /Credit Union Balance Account No. Name of Bank /Credit Union Balance 29. Savings Accounts/CD s (Including IRA s) Account No. Name of Bank /Credit Union Balance Account No. Name of Bank /Credit Union Balance 30. Stocks/Bonds Type Type Value Value 31. Do you own Real Estate? Yes No Type Type Value Value 32. Do you have Life Insurance Policies? Yes No Type of Policy Term Whole Life Company Name Head of Household X Signature Print Name Date 1/25/00 Revised 6/14/01 4/8/03 4

U.S. Department of Housing and Urban Development Office of Inspector General May 1988 Things You Should Know [)on't risk your chances for Federally assisted housing by providing false, incomplete, or inaccurate information on your application and recertification forms. Purpose This is to inform you that there is certain information you must provide when applying for assisted housing. There are penalties that apply if you knowingly omit information or give false information. Penalties for Committing Fraud The United States Department of Housing and Urban Development (HUD) places a high priority on preventing fraud. If your application or recertification forms contain false or incomplete information, you may be: Evicted from your apartment or house: Required to repay all overpaid rental assistance you received: Fined up to $10.000: Imprisoned for up to 5 years: and/or Prohibited from receiving future assistance. Your State and local governments may have other laws and penalties as well. Asking Questions When you set down with the person who fills out your application, you should know what is expected of you. If you do not understand something, say so. That person can answer your question or find out what the answer is. Completing the Application Income When you give your answers to application questions you must include the following information: All sources of money you and any member of your family receive (wages, welfare payments, alimony, social security, pension. etc.): Any money you receive on behalf of your children (child support, social security for children. etc.): Income from assets (interest from a savings account. credit union, or certificate of deposit; dividends from stocks, etc.) Earnings from second job or part time job. Any anticipated income (such as a bonus or pay raise you expect to receive). 5

Assets All bank accounts, savings bonds, certificates of deposit, stocks, real estate, etc. that are owned by you and any adult member of your family/household who will be living with you. Any business or asset you sold in the last 2 years for less than its full value, such as your home to your children. Family/Household Members The names of all of the people (adults and children) who will actually be living you, whether or not they are related to you. Signing the Application Do not sign any form unless you have read it, understand it, and are sure everything is complete and accurate. When you sign application and certification forms you are claiming that they are complete to best of your knowledge and belief. You are committing fraud if you sign a form knowing that it contains false or misleading information. Information you give on your application will be verified by your housing agency. In addition, HUD may do computer matches of the income you report with various Federal, State or private agencies to verify that it is correct. Recertifications You must provide updated information at least once a year. Some programs require that you report any changes in income or family/household composition immediately. Be sure to ask when you must recertify. You must report on recertification forms: All income changes, such as pay increases or benefits, change of job, loss of job, loss of benefits, etc., for all adult family/household members. Any family/household member who has moved in or out. All assets that you or your family/household members own and any asset that was sold in the last 2 years for less than its full value. Beware of Fraud Reporting Abuse You should be aware of the following fraud schemes: Do not pay any money to file an application. Do not pay any money to move up on the waiting list. Do not pay for anything not covered by your lease. Get a receipt for any money you pay. Get a written explanation if you are required to pay any money other than rent (such as maintenance charges). If you are aware of anyone who has falsified an application or if anyone tries to persuade you to make false statements, report them to the manager of your project or PHA. If you cannot report to the manager, call the local HUD office or the HUD hotline at (202) 472-4200. This is not a toll free number. You can also write to the HUD HOTLINE, room 8254, 451 Seventh Street, S.W., Washington, DC 20410 Applicant Signature Date 10/28/03 6

PERSONAL DECLARATION CASEVILLE HOUSING COMMISSION THIS FORM MUST BE COMPLETED IN YOUR 0WN HANDWRITING. YOU MUST USE THE CORRECT LEGAL, NAME FOR EACH MEMBER OF YOUR HOUSEHOLD AS IT APPEARS ON THE SOCIAL SECURITY CARD. ALL ADULT MEMBERS OF THE HOUSEHOLD MUST SIGN BELOW, CERTIFYING THE INFORMATION PERTAINING TO THEM. PLEASE PRINT. 1. HOUSEHOLD COMPOSITION: List all persons who will be living in your home, listing head of household first. ADULTS Legal Name, Date of Birth, Relationship, Social Security #. Name Date of Birth Relationship Soc Sec Name Date of Birth Relationship Soc Sec 2. TOTAL HOUSEHOLD INCOME: List all money earned or received by everyone living in your household. This includes money from wages, self-employment, contributions, Social Security, disability payments (SSI), Workman Compensation, retirement benefits Veterans benefits, rental property income, stock dividend, income from bank accounts, alimony, and all other sources. Name Soc Sec SSI Employment Other Name Soc Sec SSI Employment Other 3. ASSETS: - Please answer yes or no to the following questions. Do you or any household member own or have an interest in any real estate, boat, and/or mobile home? Have you sold any real estate in the last two years? Do you own any stocks or bonds? Do you have a savings accounts? If yes, give bank, account numbers and amounts. Do you own a car? Model/Year Tag No. A. Does anyone outside of your household pay any of your bills or give you money? If yes, please explain 7

B. Have you or any other adult members ever used any name(s) or Social Security number(s) other than the one you are currently using? If yes, please explain C. Have you or any member lived in any assisted housing? If yes, list where and when D. Have you or anyone in your household ever been convicted of any crime other than traffic violations? If yes, explain E. Have you ever committed any fraud in a Federally assistance Housing Program or been requested to repay money for knowingly misrepresenting information for such Housing programs? If yes, explain. I, do hereby swear and attest that all of the information above about me is true and correct. I also understand that all changes in the income of any member of the household as well as any changes in the household members must be reported to the Housing Authority in WRITING IMMEDIATELY. SIGNATURE OF HEAD OF HOUSEHOLD SIGNATURE OF SPOUSE DATE DATE WARNING! TITLE 18, SECTION 1001 OF THE UNITED STATES CODE, STATES THAT A PERSON IS GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKE FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES. 8

AUTHORIZATION Attachment 6-b for Release of Information CONSENT I authorize and direct any Federal, State, or local agency, organization, business, or individual to release to CASEVILLE HOUSING COMMISSION any Information or materials needed to complete and verify my application for participation, and/or to maintain my continued assistance under the Section 8, Rental Rehabilitation, Low-Income Public and Indian Housing, and/or other housing assistance programs. I understand and agree that this authorization or the information obtained with its use may be given to and used by the Department of Housing and Urban Development (HUD) in administering and enforcing program rules and policies. I also consent for HUD or the PHA to release information from my file about my rental history to HUD credit bureaus, collection agencies, or future landlords. This includes records on my payment history, and any violations of my lease or PHA policies. INFORMATION COVERED I understand that, depending on program policies and requirements, previous or current information regarding me or my household may be needed. Verifications and inquiries that may be requested, include but are not limited to: Identity and Marital Status Employment, Income, and Assets Residences and Rental Activity Medical or Child Care Allowances Credit and Criminal Activity I understand that this authorization cannot be used to obtain any Information about me that is not pertinent to my eligibility for and continued participation in a housing assistance program. GROUPS OR INDIVIDUALS THAT MAY BE ASKED The groups or Individuals that may be asked to release the above information (depending on program requirements) Include but not limited to: Previous Landlords (including Past and Present Employers Veterans Administration Public Housing Agencies) Welfare Agencies Retirement Systems Courts and Post Offices State Unemployment Agencies Banks and other Financial Institutions Schools and Colleges Social Security Administration Credit Providers and Credit Bureaus Law Enforcement Agencies Medical and Child Care Providers Utility Companies COMPUTER MATCHING NOTICE AND CONSENT I understand and agree that HUD or the Public Housing Authority may conduct computer matching programs to verify the information supplied for my application or recertification. If a computer match is done, I understand that I have a right to notification of any adverse information found and a chance to disprove incorrect information. HUD or the PHA may in the course of its duties exchange such automated information with other Federal, State, or local agencies, including but not limited to: State Employment Security Agencies: Department of Defense; Office of Personnel Management; the U.S. Postal Service; the Social Security Agency; and State welfare and food stamp agencies. CONDITIONS I agree that a photocopy of this authorization may be used for the purposes stated above. The original of this authorization is on file with the PHA and will stay in effect for a year and one month from the date signed. I understand I have a right to review my file and correct any information that I can prove is incorrect. SIGNATURES Head of Household (Print Name) Date Spouse (Print Name) Date NOTE: THIS GENERAL CONSENT MAY NOT BE USED TO REQUEST A COPY OF A TAX RETURN. IF A COPY OF A TAX RETURN IS NEEDED, IRS FORM 4506, "REQUEST FOR COPY OF TAX FORM" MUST BE PREPARED AND SIGNED SEPARATELY 9 ATTACHMENT 6-c

APPLICANT/TENANTS CERTIFICATION Giving True and Complete Information I certify that all the information provided on household composition, income, family assets and items for allowances and deductions, is accurate and complete to the best of my knowledge. I have reviewed the application form and the HUD Form 50058 or 50059, which ever applies to me, and certify that the information shown is true and correct. Reporting Changes In Income or Household Composition I know I am required to report immediately in writing any changes in income and any changes in the household size when a person moves in or out of the unit. I understand the rules regarding guests/visitors and when I must report anyone who is staying with me. Reporting on Prior Housing Assistance I certify that I have disclosed where I received any previous Federal housing assistance and whether or not any money is owed. I certify that for this previous assistance I did not commit any fraud, knowingly misrepresent any information, or vacate the unit in violation of the lease. No Duplicate Residence or Assistance I certify that the house or apartment will be my principal residence and that I will not obtain duplicate Federal housing assistance while I am in this current program. I will not live anywhere else without notifying the Housing Authority Immediately in writing. I will not sublease my assisted residence. Cooperation I know I am required to cooperate in supplying all information needed to determine my eligibility level of benefits, or verify my true circumstances. Cooperation includes attending pre-scheduled meetings and completing and signing needed forms. I understand failure or refusal to do so may result in delays, termination of assistance, or eviction. Criminal and Administrative Actions for False Information I understand that knowingly supplying false, incomplete or inaccurate information is punishable under Federal or State criminal law. I understand that knowingly supplying false incomplete, or inaccurate information is grounds for termination of housing assistance or termination of tenancy. Signature and Date of Household Adults 1) 2) 10