Main Office:
205 Garfield Ave | PO Box 128 | Mentor, MN 56736
Phone: 218-637-2431 | Fax: 218-637-2433

Satellite Office:
1708 River Road NW | East Grand Forks, MN 56721
Phone: 218-773-2371 | Fax: 218-773-9331

Website: www.nwmnhra.org 

APPLICATION FOR RENTAL ASSISTANCE

• You are not required to disclosed being disabled; however, benefits for which person with disabilities are entitled cannot be provided unless you disclose being disabled.
• Any changes to address, phone number, income, or family size must be reported to our office in writing.
• Only minor children who live in the unit a minimum of 50% of the time may be listed on the application. Children may not be listed on two(2) HUD applications or already be receiving rental assistance under another household.

All applications must:

• Be filled out completely. DO NOT leave any sections blank. Your application wil not be processed if anything if left blank. If a section does not apply to you, write N/A.
• Have correct, legal names, as it appears on their Social Security Card, for each person who will live in the unit.
• Be signed by all persons aged 18 years and older certifying the information is correct and accurate. They must also sign the Debts Owned to Public Housing Agencies and Terminations on pages 7-8.
• If you have already submitted an application, please do not submit another one, unless you have received a denial letter from our office. Submitting more than one application does not get you approved quicker. After receiving your application, you will be put on the waiting list, and you will be notified by mail when you are selected for the next steps.
• Preference for the Housing Choice Voucher (HCV) program is given to househlds with very low income and to those who live, work, or got to school in our service area.
• Applicants who apply outside of your service area may experience an extensive wait time and will be required to live in our service area for at least one year.

AVAILABLE PROGRAMS

• Housing Choice Voucher (HCV) Program 
  Participants pay a minimum of 30% of their adjusted annual income for rent and utilities. We provide assistance in the counties of Kittson, Lake of the Woods, Marshall, Norman, Pennington, Polk*, Red Lake, and Roseau.
        *Limited availability in the City of Crookston

• Public Housing
  These units are income based, and housing choice vouchers are not accepted. Assistance remains with the units and does not transfer when the participant moves. Participants pay a minimum of 30% of their adjusted income for rent and utilities.

• Project Based Townhouses - Must complete this application as well as the Project Based Application
  Units are income-based and participants must also qualify with D.W. Jones Management Company for rent assistance in particular units.

• HRA Owned Rental Properties - Requires a separate application. Contact NW MN Multi-County HRA for the application
  There units are market-rate, but HCVs are accepted. All units are in Polk County. Units include:
  • 1 and 2 bedroom duplexes in Fosston and McIntosh
  • 1 and 2 bedroom apartments in McIntosh and East Grand Forks (must be 55+ to quailfy for East Grand Forks)
  • 1 bedroom apartments in Mentor, MN

List all people, including yourself, who will be a part of the household.
Use the following to fill in information about each household member below
Disability: Y=Yes N=No D=Decline to Answer
Citizenship: E=Eligible Citizen EN=Eligible Non-Citizen I=Ineligible Citizen P=Pending Verification
Gender: M=Male F=Female O=Other
Race: A=Asian B=Black/African American I=American Indian/Alaskan Native W=White P=Native Hawaiian/Pacific Islander
Ethnicity: H=Hispanic NH=Non-Hispanic

List all current amounts of assets in your household. All listed assets may require additional proof to be provided.

List the MONTHLY amount of gross income that your household receives. Gross income is the total income received before subtracting taxes or other deductions. All income listed will require additional proof to be provided.

My signature below certifies that I have read, understand, and agree with the following:

• The information given to Northwest Minnesota Multi-County Housing and Redevelopment Authority on household composition, income, assets, allowances, and deductions is accurate and complete to the best of my knowledge and belief. If any information is false, I understand that this application will be denied.
  
  

• Any false statements or information are punishable under Federal Law. I understand that false statements or information are grounds for denial of this application, termination of housing assistance, and/or termination of tenancy. IF YOU FALSIFY ANY INFORMATION YOUR APPLICATION WILL BE DENIED.
  
  

• Only minor children who live in the unit a minimum of 50% of the time may be listed on the application and children may not be listed on two HUD applications or already be listed on a household receiving assistance. I certify that any minor child(ren) listed on this application live in the household 50% of the time and they are not receiving housing assistance through another household that I am aware of.
  
  

• I am required to notify Northwest Minnesota Multi-County HRA in writing of any changes to mailing address. I understand that if NW MN Multi-County HRA is unable to contact me at the address provided, my application will be removed from the waiting list, and I will have to reapply for assistance.
  
  

• All address, income, or family size changes to my application must be made in writing to Northwest Minnesota Multi-County HRA.
  
  

• I/We authorize Northwest Minnesota Multi-County Housing and Redevelopment Authority to conduct a criminal background check for all household members 18 years of age and older listed on this application.

If you believe you have been discriminated against, you may call the U.S. Department of HUD, Fair Housing and Equal Opportunity Chicago Regional Office, Toll-Free Hotline at 1-800-765-9372, TTY 312-353-7143. After verification by Northwest Minnesota Multi-County HRA, the information is 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 or anyone in your household is a person with disabilities and you require a specific accommodation to fully utilize our programs and services, please contact the housing authority at 218-637-2431

OMB No. 2577-0266        Expires 06/30/2026

Paperwork Reduction Notice: Public reporting burden for this collection of information is estimated to average 7 minutes per response. This includes the time for respondents to read the document and certify, and any record keeping burden. This information will be used in the processing of a tenancy. Response to this request for information is required to receive benefits. This agency may not collect this information, and your are not required to complete this form, unless it displays a currenly valid OMB control number. The OMB Number is 2577-0266, and expires 06/30/2026.

NOTICE TO APPLICANTS AND PARTICIPANTS OF THE FOLLOWING HUD RENTAL ASSISTANCE PROGRAMS:

• Public Housing (24 CFR 960)
• Section 8 Housing Choice Voucher, including the Disaster Housing Assistance Program (24 CFR 982)
• Section 8 Moderate Rehabilitation (24 CFR 882)
• Project-Based Voucher (24 CFR 983)

The U.S. Department of Housing and Urban Development maintains a national repository of debts owed to Public Housing Agencies (PHAs) or Section 8 landlords and adverse information of former participants who have voluntarily or involuntarily terminated participation in one of the above-listed HUD rental assistance programs. This information is maintained within HUD's Enterprise Income Verification (EIV) system, which is used by Public Housing Agencies (PHAs) and their management agents to verify employment and income information of program participants, as well as, to reduce administrative and rental assistance payment errors. The EIV system is designed to assist PHAs and HUD in ensuring that families are eligible to participate in HUD rental assistance programs and determining the correct amount of rental assistance a family is eligible for. All PHAs are required to use this system in accordance with HUD regulations 24 CFR 5.233.

HUD requires PHAs, which administers the above-listed rental housing programs, to report certain information at the conclusion of your participation in a HUD rental assistance program. This notice provides you with information on what information the PHA is required to provide HUD, who will have access to this information, how this information is used and your rights. PHAs are required to provide this notice to all applicants and program participants and you are required to acknowledge receipt of this notice by signing page 2. Each adult household member must sign this form.

What information about you and your tenancy does HUD collect from the PHA?
The following information is collected about each member of your household (family composition): full name, date of birth, and Social Security Number.

The following adverse information is collected once your participation in the housing program has ended, whether you voluntarily or involuntarily move out of an assisted unit:

1. Amount of any balance you owe to the PHA or Section 8 landlord (up to $500,000) and explanation for balance owed (i.e. unpaid rent, retroactive rent due to unreported income and/or change in family composition) or other changes such as damages, utility charges, etc.); and
2. Whether or not you have entered into a repayment agreement for the amount you owe the PHA; and
3. Whether or not you have defaulted on a repayment agreement; and
4. Whether or not the PHA has obtained a judgement against you; and
5. Whether or not you have filed for bankruptcy; and
6. The negative reason(s) for your end of participation or any negative status (i.e., abandonded unit, fraud, lease violations, criminal activity, etc.) as of the end of participation date.

OMB No. 2577-0266    Expires 06/30/2026

2

Who will have access to the information collected?
This information will be available to HUD employees, PHA employees, and contractors of HUD and PHAs.

How will this information be used?
PHAs will have access to this information during the time of application for rental assistance and reexamination of family income and composition for existing participants. PHAs will be able to access this information to determine a family's suitability for initial or continued rental assistance, and avoid providing limited Federal housing assistance to families who have previously been unable to comply with HUD program requirements. If the reported information is accurate, a PHA may terminate your current rental assistance and deny your future request for HUD rental assistance, subject to PHA policy.

How long is the debt owed and termination information maintained in EIV?
Debt owed and termination information will be maintained in EIV for a period of up to ten (10) years from the end of participation date or such other period consistent with State Law.

What are my rights?
In accordance with the Federal Privacy Act of 1974, as amended (5 USC 552a) and HUD regulations pertaining to its implementation of the Federal Privacy Act of 1974 (24 CFR Part 16), you have the following rights:

1. To have access to your records maintained by HUD, subject to 24 CFR Part 16.
2. To have an administrative review of HUD's initial denial of your request to have access to your records maintained by HUD.
3. To have incorrect information in your record corrected upon written request.
4. To file an appeal request of an initial adverse determination on correction or amendment of record request within 30 calendar days after the issuance of the written denial.
5. To have your record disclosed to a third party upon receipt of your written and signed request.

What do I do if I dispute the debt or termination information reported about me?
If you disagree with the reported information, you should contact in writing the PHA who has reported this information about you. The PHA's name, address, and telephone numbers are listed on the Debts Owed and Termination Report. You have a right to request and obtain a copy of this report from the PHA. Inform the PHA why you dispute the information and provide any documentation that supports your dispute. HUD's record retention policies at 24 CFR Part 908 and 24 CFR Part 982 provide that the PHA may destroy your records three years from the date your participation in the program ends. To ensure the availability of your records, disputes of the original debt or termination information must be made within three years from the end of participation date; otherwise the debt and termination information will be presumed correct. Only the PHA who reported the adverse information about you can delete or correct your record. Your filing of bankruptcy will not result in the removal of debt owed or termination information from HUD's EIV system. However, if you have included this debt in your bankruptcy filing and/or this debt has been discharged by the bankruptcy court, your record will be updated to include the bankruptcy indicator.
The PHA will notify you in writing of its action regarding your dispute within 30 days of receiving your written dispute.
If the PHA determines that the disputed information is incorrect, the PHA will update or delete the record. If the PHA determines that the disputed information is correct, the PHA will provide an explanation as to why the information is correct.

This Notice was provided by the below-listed PHA:
Northwest Minnesota Multi-County HRA
PO Box 128
Mentor, MN 56736

I hereby acknowledge that the PHA provided me with the Debts owed to PHAs & Termination Notice:

OMB Control # 2503-0581
Exp. (02/28/2019)

Supplemental and Optional 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 Oganization: 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 resoliving any issues that may arise during your tenacy 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.

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 service or special care, we may contact the person or oganization you listed to assist in resolving the issue 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 Octover 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 CFE 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.

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 (44U.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 Comm unity 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 fradulent actions.

Form HUD-92006 (05/09)