APPLICATION FOR OCCUPANCY

Rental History

Please enter the information requested for your current address and the two most recent prior addresses within the past 5 years.
Enter only your residences at the age of 18 years old and older
Current Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Monthly Rent
Name Rented Under

First NameLast Name
Landlord Name

First NameLast Name
Landlord Phone #
Please enter a valid phone number.
Names of Household Members
Reason for moving
Move-in Date Security Dep. $
Do you have an executed lease agreement at the above address?

YesNo
Previous Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Monthly Rent
Name Rented Under

First NameLast Name
Landlord Name

First NameLast Name
Landlord Phone #
Please enter a valid phone number.
Names of Household Members
Move-in date

MonthDayYear
Move out date

MonthDayYear
Did you fulfill the lease term?

YesNo
Reason for moving
Previous Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Monthly Rent
Name rented under

First NameLast Name
Landlord Name

First NameLast Name
Landlord Phone #
Please enter a valid phone number.
Names of Household Members
Move-in date

MonthDayYear
Move out date

MonthDayYear
Did you fulfill the lease term?

YesNo
Reason for moving

Statements by All Adult Household Members
      I/We certify that all information given in this application and any addendum thereto is true, complete and accurate. We understand that if any of this information is false, misleading or incomplete, management may decline our application or, if move-in has occurred, terminate our Rental Agreement.
       I/We authorize the housing authority of the city of Dumas to make any and all inquiries to verify this information either directly or through information exchanged now or later with rental and credit screening services, and to contact previous and current landlords or other sources for credit and verification confirmation which may be released to appropriate Federal, state or local agencies.
       I/We agree to notify management in writing regarding any changes in household address, telephone numbers, income, and household composition while active on the waiting list.
      I/We have been notified that the Resident Selection Criteria, which summarizes the procedures for processing applications, is posted in the management office.
       I/We understand that if this application is placed on a Waiting List, we may request sample copies of the Rental Agreement and House Rules. If this application is approved and move-in occurs, we certify that we will accept and comply with all conditions of occupancy as set forth therein, including specifically all conditions regarding pets, rent, damages, and security deposits.
      I/We authorize management to obtain one or more “consumer reports” as defined in the Fair Credit Reporting Act, 15 U.S. C. Section 1681a(d), seeking information on our creditworthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living, also to include rental references and criminal background inquiries.
Signature of Head of Household

Clear
Date

MonthDayYear
Signature of Spouse/ Co-Head/ Co-Applicant

Clear
Date

MonthDayYear
Signature of Co-Applicant

Clear
Date

MonthDayYear
Signature of Co-Applicant

Clear
Date

MonthDayYear
Date
PENALTIES FOR MISUSING THIS CONSENT:
Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposes cited above. Any person who knowingly or willingly 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 or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Act at 208 (a) (6), (7) and (8). Violation of these provisions are cited as violations of 42 U.S.C. 408 (a) (6), (7) and (8).

Optional and Supplemental Contact Information for HUD-Assisted Housing Applicants
SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING

This form is to be provided to each applicant for federally assisted housing Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing, the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update, remove, or change the information you provide on this form at any time. You are not required to provide this contact information, but if you choose to do so, please include the relevant information on this form.
Applicant Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Name of Additional Contact Person or Organization:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to Applicant
Reason for Contact: (Check all that apply)

EmergencyUnable to contact youTermination of rental assistanceEviction from unitLate payment of rentAssist with Recertification ProcessChange in lease termsChange in house rulesOther
Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the issues or in providing any services or special care to you.

Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the applicant or applicable law.

Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992) requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or organization. By accepting the applicant’s application, the housing provider agrees to comply with the non-discrimination and equal opportunity requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on age discrimination under the Age Discrimination Act of 1975.
Signature of Applicant

Clear
Date

MonthDayYear
The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520). The public reporting burden is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the obligation to require housing providers participating in HUD’s assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in the application for occupancy the name, address, telephone number, and other relevant information of a family member, friend, or person associated with a social, health, advocacy, or similar organization. The objective of providing such information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any delivery of services or special care to the tenant and assist with resolving any tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and maintained as confidential information. Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and management controls that prevent fraud, waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless the collection displays a currently valid OMB control number. Privacy Statement: Public Law 102-550, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be used by HUD to protect disbursement data from fraudulent actions.

WAITING LIST ACKNOWLEDGEMENT

I HEREBY ACKNOWLEDGE THAT I HAVE RECEIVED A COPY OF THE TENANT SELECTION CRITERIA, A COPY OF THE HUD RIGHTS AND RESPONSIBILITIES HANDBOOK, A COPY OF THE HUD FACT SHEET, A COPY OF THE EIV AND YOU BROCHURE, A COPY OF DO YOU HAVE A SOCIAL SECURTIY NUMBER? (SSN) AND A COPY OF THE HUD FRAUD PREVENTION HANDOUT FOR THE HOUSING AUTHORITY OF THE CITY OF DUMAS. I UNDERSTAND IT IS MY RESPONSIBILITY TO READ THE CRITERIA AND TO DETERMINE IF I FEEL I AM ELIGIBLE FOR RESIDENCY AT THE HACD. I UNDERSTAND THAT ALL INFORMATION I PROVIDE ON MY APPLICATION, OR IN MY APPLICATION PACKET, WILL BE VERIFIED PRIOR TO MY BEING OFFERED AN APARTMENT AT THE HACD.

I FURTHER ACKNOWLEDGE THAT I AM AWARE THAT IT IS GROUNDS FOR AUTOMATIC REJECTION IF I PROVIDE FALSE DATA ON MY APPLICATION, OR FAIL TO RETURN ALL REQUIRED DOCUMENTS.
Acknowledged this on Date
Applicant Signature

Clear
Date

MonthDayYear
Applicant Signature

Clear
Date

MonthDayYear
Authorization for the Release of Information Privacy Act Notice
to the U.S. Department of Housing and Urban Development(HUD) and the Housing Agency/Authority(HA)

Authority: Section 904 of the Stewart B. McKinney Homeless Assistance Amendments act of 1988, as amended by Section 903 of the Housing and Community Development Act of 1992 and Section 3003 of the Omnibus Budget Reconciliation Act of 1993. This law is found at 42 U.S.C. 3544.

This law requires that you sign a consent form authorizing: ( 1) HUD and the Housing Agency/ Authority (HA) to request verification of salary and wages from current or previous employers;(2) HUD and the HA to request wage and unemployment compensation claim information from the state agency responsible for keeping that information; (3) HUD to request certain tax return information from the U.S. Social Security Administration and the U.S. Internal Revenue Service. The law also requires independent verification of income information. Therefore, HUD or the HA may request information from financial institutions to verify your eligibility and level of benefits.

Purpose: In signing this consent form, you are authorizing HUD and the above-named HA to request income information from the sources listed on the form. HUD and the HA need this information to verify your household's income, in order to ensure that you are eligible for assisted housing benefits and that these benefits are set at the correct level. HUD and the HA may participate in computer matching programs with these sources in order to verify your eligibility and level of benefits.

Uses of Information to be Obtained: HUD is required to protect the income information it obtains in accordance with the Privacy Act of 1974, 5 U.S.C. 552a. HUD may disclose information
(other than tax return information) for certain routine uses, such as to the other government agencies for law enforcement purposes, to Federal agencies for employment suitability purposes and to HAs for the purpose of determining housing assistance. The HA is also required to protect the income information it obtains in accordance with any applicable State privacy law. HUD and HA employees may be subject to penalties for unauthorized disclosures or improper uses of the income information that is obtained based on the consent form. Private owners may not request or receive information authorized by this form.

Who Must Sign the Consent Form: Each member of your household who is 18 years of age or older must sign the consent fonn. Additional signatures must be obtained from new adult members joining the household or whenever members of the household become 18 years of age.

Persons who apply for or receive assistance under the following programs are required to sign this consent form:

PHA-owned rental public housing Turnkey III Homeownership Opportunities Mutual Help Homeownership Opportunity Section 23 and 19( c) leased housing Section 23 Housing Assistance Payments HA-owned rental Indian housing
Section 8 Rental Certification
Section 8 Rental Voucher
Section 8 Moderate Rehabilitation

Failure to sign Consent Form: Your failure to sign the consent form may result in the denial of eligibility or termination of assisted housing benefits, or both. Denial of eligibility or termination of benefits is subject to the HA's grievance procedures and Section 8 informal hearing procedures.

Sources of Information To Be Obtained

State Wage Information Collection Agencies. (This consent is limited to wages and unemployment compensation I have received during period(s) within the last 5 years when I have received assisted housing benefits.)

U.S. Social Security Administration(HUD only) (This consent is limited to wage and self employment information and pay-
ments of retirement income as referenced at Section 6103(1)(7)(A) of the Internal Revenue Code.)

U.S. Internal Revenue Service (HUD only) (This consent is limited to unearned income [i.e., interest and dividends].)

Information may also be obtained directly from: (a) current and former employers concerning salary and wages and (b) financial institutions concerning unearned income (i.e., interest and dividends). I understand that income information obtained from these sources will be used to verify information that I provide in determining eligibility for assisted housing programs and the level of benefits. Therefore, this consent form only authorizes release directly from employers and financial institutions of information regarding any period(s) within the last 5 years when I have received assisted housing benefits.
Head of Household

Clear
Date

MonthDayYear
Social Security Number (if any) of Head of Household
Spouse

Clear
Date

MonthDayYear
Other Family Members over age 13

Clear
Date

MonthDayYear
Other Family Members over age 13

Clear
Date

MonthDayYear
Other Family Members over age 13

Clear
Date

MonthDayYear
Should be Empty:

	Full Name	Relationship	Sex	Birthdate	SSN
1.
2.
3.
4.
5.
6.
7.
8.

	Family Member	Source	Rate & Frequency	Annually
1.
2.
3.
4.
5.
6.
7.
8.
Total


Annual Income
$480.00 Per Dependent
$400.00 For Elderly/Disable
Medical
Child Care
Total Deductions
Adjusted Income
30% of Adjusted Income
Divided by 12 Months
Utility Allowance
Tenant Rent