Caraway Housing Authority

I herby consent to the following:

The use of the attached evidence to verify my eligible immigration status to enable me to receive financial assistance housing :
The release of such evidence of eligible immigration status by the project owner without responsibility for the further use or transmission of the evidence by the entity receiving it, to; (a) HUD, as required by HUD; and (b) The INS for the purposes of verification of the immigration status of the individual. Notification: Evidence of eligible immigration status shall be released only to the INS for purposes of establishing eligibility for financial assistance and not for any other purpose. HUD is not responsible for the further use or transmission of the evidence or other information by the INS.
Signature

Clear
Displacement
Is the applicant family displaced by a declared Natural Disaster, such as a flood, hurricane, earthquake, etc? If yes, please give the name, address, and telephone number of the person who can verify this and the government agency issued number you received for disaster distance.
Is this applicant family displaced by government action through no fault of their own? If yes, print the name, address, and telephone number of the government agency that can verify this.
Is this applicant family displaced by domestic violence? If yes, please give the name, address, and telephone number of the person who can verify this.
Employment Information
List all family members name, address, and telephone number of employers.
Is any adult family member enrolled in a job-training program, including one required under the Welfare program? If yes, please give the name, address, and telephone number of the institution they are attending.

Family Income Information
Has anyone in the household ever received EARNED INCOME DISALLOWANCE?

YesNo
Please list the source and amount of all income expected for the coming 12 months for all family members, including yourself. Include all earnings and benefits received from current job, last previous job, AFCD/TANF, Social Security, SSI, SSID, Unemployment, Worker's Compensation, Child Support, babysitting, cleaning houses, etc. Example: Wages= $150.00/ Week, SSI= $200/ Month.

Please enter in income sources

	Name	Income Sources	Amount	How Often
1.
2.
3.
4.

Do you receive food stamps?

YesNo
What is the amount per month?
From what County:
Do you have a checking or savings account or own any Certificates of Deposit, stocks, bonds, etc.? If yes, describe the type of asset and the market value.
Do you own any real estate or have you sold any real estate in the past 2 years?

YesNo
What is the address?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

State Lifetime Sex Offender Registration

Please answer the following required questions
Is the applicant or any member of the applicant's household subject to a lifetime sex offender registration program in any state?*

YesNo
Please list:
A signature of the Head of Household and all others that are 18 years of age and older only on the application release line. The CHA staff member will mail the Criminal Back Ground, the Landlord Verification, and the Employment Verification. If there is more than one member of the household working, please let the CHA staff know and we will give an extra Employment Verification Form to you. Please remember do not fill out the information.
A 214 Status is required by each applicant to fill out. If an applicant is under the age of 18 the parent must fill out and sign. If more sheets are needed, please let the CHA staff know and we will give extras.
Criminal Back Ground Checks

*We will be running Criminal Back Ground Checks on each individual over the age of 18.
Have you or any other member of the applicant household ever been arrested or convicted of a crime other than a traffic violation?

YesNo
Please Explain:
Pets
Do you have a pet that you wish to bring with you?

YesNo
We have a very strict pet policy that must be followed in order to have a pet. You will always be required to pay an additional $200.oo NON--REFUNDABLE pet fee. All information on the pet policy must be complete prior to being allowed to move in.
What type of pet do you own?
Has it been spayed or neutered?

YesNo
Please list the name, address, and phone number the pets veterinarian:

Full-Time Student Information
Name of Educational Institution:
Contact Person and Phone Number to Verify Information
Vehicle Information

Please enter vehicle information:

	Primary Driver:	Automobile Color:	Year:	Make:	Model:	License Plate Number:
First Car
Second Car

The Housing Authority will be contacting all former landlords.
Have you ever lived in Public Housing:

YesNo
When and where?
Do you owe them any money?

YesNo
Why did you move from that locations?
Have you ever been evicted from any type of housing?

YesNo
Where do you live now?

I am renting an apartment/house.I am living with a family member/friend.I own my own home.
Most current physical address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Most current landlord's name or person you are living with phone number:
How long did you or have you been living at this address?
Previous Physical Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous landlord's name and phone number:
How long did you live there?
Did you leave owing them any money:
If you own your home, what is the address?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your reason for moving?

To complete your application, your current landlord will need to complete a form. Please email your landlord this link. They will need to include the following information on the form:
- Your name
- Other things the form asks for
Once they submit the form it will go to the Caraway Housing Authority
Name of Applicant:

First NameLast Name
Current Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Landlord:

First NameLast Name
Landlord Contact Info:
Notice That Resident May Request a Reasonable
Accommodation for a Disabled Member

You are notified that at any time during your occupancy you may request a reasonable accommodation of the unit for a disabled household member. This would include reasonable accommodations that would allow the household member to meet dwelling lease requirements or other requirements of occupancy.

Your request must be submitted in writing to the housing manager at the rental office. The request must specify the type of accommodation needed, and state the reason the accommodation is needed for the family member.

The PHA may verify the nature of the disability and the extent of necessary reasonable accommodation to be supplies. If the PHA has the accommodations available, you can be transferred to another unit.
Head of Household:

First NameLast Name
Date:

MonthDayYear
Housing Representative:
Date

MonthDayYear
Citizenship and Eligible Immigrant Status (24 CFR 5.506)

To receive housing assistance all family members must either be citizens or nationals of the United States or eligible immigrants. Persons who are U.S. citizens or nationals may certify to their status. Persons who are not U.S. citizens or nationals have two choices. Immigrants may either claim or document their eligibility for housing assistance, or they may choose not to co tend their status and relinquish housing assistance. Relinquishing housing assistance does not necessarily mean that the undocumented family member cannot reside with the assisted family or should leave the assisted housing. Those who qualify as eligible immigrants are treated differently based upon their age. Immigrants who are 62 years of age or older can sign a declaration of eligible immigrant status and provide proof of age. Immigrants who are younger must sign a declaration of eligible immigrant status, and provide the PHA one of the documents accepted by the Immigration and Naturalization Service (INS), and a signed verification consent form. Immigrants may choose not to contend that they have eligible status and still be housed in or remain in the assisted housing. So long as at least one lone family member is either a citizen or an eligible immigrant, the family with qualify as a "mixed family'' under 24 CFR. 5.504 and will have their housing assistance pro-rated (which mean they will pay a higher rent than they would if all family members were either citizen or eligible immigrants).

Disclosure of Social Security Number

(24CFR 5.216) Applicants for public housing are required to document the Social Security members of all family members or certify that an individual does not have a Social Security number. Refusal to provide a Social Security number or certification renders an applicant ineligible for public housing.

I/we certify that the statements on this application are true to the best of my/our knowledge and belief. and understand that will be verified. I/we authorize the release of information to the Caraway Housing Authority by my/our employer(s), the Department of Public Assistance, the Social Security Administration, and/or other business or government agencies. I/we understand that any false statements made on this application will cause me/us to be disqualified for admission.
Applicant Signature

Clear
Date

MonthDayYear
Co-Applicant Signature

Clear
Date

MonthDayYear
Warning: 18 U.S.C 1001 provides, among other things that whoever knowingly and willfully makes or uses a document writing containing false, fictitious, or fraudulent statements or entry in any matter within the jurisdiction of a department agency of the United States shall be fined not more than $10,000 or imprisoned for not more than 5 years, or both.
How did you learn about the Caraway Housing Authority?
Waiting List Placement

I am aware that the waiting list follows a chronological order from when the application is completed and turned in to the Caraway Housing Authority.
(handicapped and elderly get priority placement) I am also aware that it cannot be filed as completed until I have supplied a copy of the driver's license, birth certificate, social security card, and proof of income for each family member to a CHA staff member.

By signing below, I am stating that I am aware of the Placement Policy and have given a copy of each of the requested papers to the Caraway Housing Authority.
Applicant Signature

Clear
Date

MonthDayYear
HUD Form 9886
Consent: I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form for the purpose of verifying my eligibility and level of benefits under HUD's assisted housing programs. I understand that HAs that receive income under this consent form cannot use it to deny, reduce or terminate assistance without first independently verifying what the amount was, whether I actually had access to the funds and when the funds were received. In addition, I must be given an opportunity to contest those determinations. This consent form expires 15 months after signed.
Signature

Clear
Head of Houshold

First NameLast Name
Date

MonthDayYear
Social Security Number (if any) of Head of Houshold

Additional Family Information

	Name	Date
Spouse
Other Family Member over age 18
Other Family Member over age 18
Other Family Member over age 18
Other Family Member over age 18
Other Family Member over age 18
Other Family Member over age 18

Privacy Act Notice. Authority: The Department of Housing and Urban Developemtn (HUD) is authorized to collect this information by the U.S. Housing Act of 1937 (42 U.S.C. 1437 et. seq), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and by the Fair Housing Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants and participants to submit the Social Security Number of each houshold member who is six years old or older. Purpose: Your income and other information are being cllected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your family will pay towards rent and utilities. Other uses: HUD uses your family income and other information to assist in managing and monitoring HUD-assisted housing programs, to protect the Governments financial interest, and to verify the accuract of the information you provide. This information may be released to Federal, State, and local agencies, when relevent, and to civil, criminal or regulatory investigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law. Penalty: You must provide all of the information requested by the HA, including all Social Security Numbers you, and all other houshold members age six years and older is mandatory, and not providing the Social Security Numbers of all household members will affect your eligibility. Failure to provide any of the requested information may result in a delay or rejection of your eligibility approval.
Penalties for Misusing this Consent:

HUD, the HA and any owner (or any employee of HUD, the HA or the owner) may be subject to penalities for unauthorized disclosures or improper uses of information collected based on the consent form.

Use of the information collected based on the form HUD 9886 is restricted to the purposes cited on the form HUD 9886. Any person who knowlingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000.

Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the HA or the owner responsible for the unauthorized disclosure or improper use.

	Child's Full Name	Case Number	Case Worker's Name	County
Child 1
Child 2
Child 3
Child 4

Caraway Housing Authority

Application for Public Housing