Information for Program Eligibility

Information for Program Eligibility
Name*

First NameMiddle InitialLast Name
Address*

Street Address

Apt/Lot/Unit

CityState / Province

Postal / Zip Code
Cell Phone
Home Phone
Email Address
example@example.com
FAMILY COMPOSITION

List ALL household members (including yourself) who will live in the unit. Children listed must live with you at least 50% of the time and MAY NOT receive housing assistance in another household.
How many household members do you have to add?*
Family Member #1

YOURSELF/HEAD OF HOUESHOLD
First Name*
Middle Initial
Last Name*
Sex*
Birth Date*

MonthDayYear
Date
Disabled*
Social Security Number*
Place of Birth (City and State)*
Race

WhiteBlack/African AmericanNative American/Alaskan NativeAsia/Pacific Islander
Ethnicity

HispanicNon-Hispanic
Family Member #2
First Name*
Middle Initial
Last Name*
Sex*
Birth Date*

MonthDayYear
Date
Disabled*
Social Security Number*
Place of Birth (City and State)*
Family Member #3
First Name*
Middle Initial
Last Name*
Sex*
Birth Date*

MonthDayYear
Date
Disabled*
Social Security Number*
Place of Birth (City and State)*
Family Member #4
First Name*
Middle Initial
Last Name*
Sex*
Birth Date*

MonthDayYear
Date
Disabled*
Social Security Number*
Place of Birth (City and State)*
Family Member #5
First Name*
Middle Initial
Last Name*
Sex*
Birth Date*

MonthDayYear
Date
Disabled*
Social Security Number*
Place of Birth (City and State)*
Family Member #6
First Name*
Middle Initial
Last Name*
Sex*
Birth Date*

MonthDayYear
Date
Disabled*
Social Security Number*
Place of Birth (City and State)*
Family Member #7
First Name*
Middle Initial
Last Name*
Sex*
Birth Date*

MonthDayYear
Date
Disabled*
Social Security Number*
Place of Birth (City and State)*
Family Member #8
First Name*
Middle Initial
Last Name*
Sex*
Birth Date*

MonthDayYear
Date
Disabled*
Social Security Number*
Place of Birth (City and State)*
Family Member #9
First Name*
Middle Initial
Last Name*
Sex*
Birth Date*

MonthDayYear
Date
Disabled*
Social Security Number*
Place of Birth (City and State)*
Family Member #10
First Name*
Middle Initial
Last Name*
Sex*
Birth Date*

MonthDayYear
Date
Disabled*
Social Security Number*
Place of Birth (City and State)*
Family Member #11
First Name*
Middle Initial
Last Name*
Sex*
Birth Date*

MonthDayYear
Date
Disabled*
Social Security Number*
Place of Birth (City and State)*

APPLICANT(S) STATEMENT:
- I/We certify that the information given to Northwest Minnesota Multi-County Housing Authority on household composition, income, family assests, allowances, and decustions is accurate and complete to the best of my/our knowledge and belief.
- I/We certify that false statements or information are punishable under Federal Law. I/We also understand that false statements or information are ground for termination of housing assistance and termination of tenancy.
- I/We certify that any minor child(ren) listed reside in the unit at least 50% of the time. I/We also certify that any minor child(ren) listed are not receiving housing assistance through another household that I/we are aware of.
- I/We authorize Northwest Minnesota Multi-County HRA to conduct a criminal background check for all adult household member (18 years of age and older) listed on this form.
Signature of Head of Household*

Clear
Date*

MonthDayYear
Date
How many more adults 18 years or older need to sign this form?
Signature of Adult Member*

Clear
Date*

MonthDayYear
Date
Signature of Adult Member*

Clear
Date*

MonthDayYear
Date
If you believe you have been discriminated against, you may call the U.S. Dept. of HUD, Fair Housing and Equal Opportunity Chicago Rengial Office, Toll-Free Hot Line at 800-765-9372. TTY (312)353-7142.

After verification by this Housing Agency, the information will be submitted to the Department of Housing and Urban Development on Form HUD-50058 (Tenant Data Summary). See the Federal Privacy Act Statement for more information about its use.

If you are anyone in your household is a person with disabilities, and you require a specific accommodation to fully utilitze our programs and services, please contact the housing authority at 218-637-2431
Should be Empty:

Information for Program Eligibility

FAMILY COMPOSITION

Family Member #1

Family Member #2

Family Member #3

Family Member #4

Family Member #5

Family Member #6

Family Member #7

Family Member #8

Family Member #9

Family Member #10

Family Member #11

Income for all Household Members

Employment

Employment #1

Employment #2

County Financial Assistance

Child Support Income

Social Security and/or RSDI (including income for minor children)

Supplemental Security Income/SSI (including income for minor children)

Veteran's Compensation

Self-Employment Income OR Cashed Received for Odds Jobs

Unemployment Benefits OR Severance Pay

Alimony OR Spousal Maintenance

Regular Payments from Pension (PERA, Railroad, etc.)

Regular Payment from Annuities, Life Insurance, Inheritance, Insurance Settlements, Lottery, etc.

Income from Rental Property

Regular Monetary Assistance form Others (rent, utilities, insurance, cellphone, gas, tobacco, etc.)

Other Income

Assets

Medical Expenses