application and personal declaration . and personal declaration ... you may call the fair housing...

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APPLICATION

AND PERSONAL DECLARATION __________________________________________________________________________

Thank you for your interest in the Lawrence-Douglas County Housing Authority (LDCHA). This application can be used to request placement on waiting lists for the following housing programs:

GENERAL HOUSING - LDCHA rental units and/or assistance to rent from private landlords. The LDCHA does not have separate waiting lists for public housing units or Section 8 Housing Choice Vouchers. These housing programs are filled through the General Housing waiting list.

SENIOR HOUSING - LDCHA rental units for elderly residents at Babcock Place, Peterson Acres, and Peterson Acres II with 2 bedroom handicapped accessible units.

HOMELESS TRANSITIONAL HOUSING - 24 months of rent assistance for homeless families with referral from a participating support service agency and certification of homelessness.

Bert Nash CSS Transitional Housing – 24 months of rent assistance for persons referred by the Bert Nash Community Support Services program.

Clinton Place Apartments – One bedroom subsidized apartments for elderly and persons with disabilities. To apply for housing with the LDCHA:

Fill out the attached application packet consisting of: 1. LDCHA Application Form 2. HUD Form-9886/9887, Privacy Act 3. LDCHA Release of Information

Leave no blank spaces. If a question does not apply to any member of your household write N/A on the form. Double check to make sure your application is complete, all forms signed and dated. Attach copies of Social Security cards and birth certificates for all family members including A valid driver’s license or valid identification card for members of the household 18 years or older. Attach proof of income. 3 Months of pay check stubs, SS/SSDI letter, child support/alimony, SRS

cash assistance, food stamps letter, family contributions, retirement income, unemployment income, workers compensation, interest/dividend income, tribal allotments, student financial aid, IRA’s, annuity and investments, money market accounts.

3 months of bank statements including savings accounts. Attach Medical Verification of pregnancy from a health care provider, if applicable. Debts owed to Public Housing Form needs to be signed by all adults Fill out the Residential History Worksheet for all adults listed on the application Court custody documents or a notarized letter from the parents stating custody Deliver your completed forms to:1600 Haskell Avenue, Lawrence, KS 66044

You will be mailed a letter verifying that your application has been processed. All information provided as part of an application will be verified. Withholding information or giving false, misleading, or incomplete information will be grounds for denial of housing through the LDCHA.

Incomplete or unsigned application forms will be destroyed. Persons with disabilities who need assistance completing this application may request reasonable accommodation under the LDCHA Reasonable Accommodation Policy. A reasonable accommodation request form can be obtained from the LDCHA offices at 1600 Haskell Avenue or 1700 Massachusetts. Contact the housing authority at 785-842-8110 if you need more information about applying for housing assistance. NOTE TO APPLICANT: If you believe you have been discriminated against, you may call the Fair Housing and Equal Opportunity National Toll – Free Hot Line (800) 743-5323

Staff Use Only: Date & Time Stamp ___________________________________________________________________ Record ID # ______________ Head of Household Last Name: ______________________________________________

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LDCHA APPLICATION and PERSONAL DECLARATION PRINT OR TYPE WITH INK – FILL IN ALL BLANKS – SIGN AND DATE BACK OF FORM MARK ALL WAITING LISTS YOU WANT TO APPLY FOR GENERAL HOUSING: Permanent housing in LDCHA rental units or voucher assistance to rent from private landlords. SENIOR HOUSING - Permanent housing units: Babcock Place: Studio, 1 bedroom and 2 bedroom units. Must be over age 50 to apply. Peterson Acres: 1 bedroom units. 2 bedroom handicapped accessible units. Must be over age 50 to apply. Clinton Place Apartments: 1 bedroom units. Must be over age 50 or a person with disabilities to apply. TRANSITIONAL HOUSING - 24 months of tenant-based rent assistance: HOMELESS TRANSITIONAL HOUSING. Requires support service agency referral and certification of homeless status. BERT NASH CSS TRANSITIONAL HOUSING. Requires referral by the Bert Nash CSS program. Applicants are considered for housing without regard to race, sex, religion, color, national origin, age, ancestry, marital status, sexual orientation, gender identification, and/or disability. To help us comply with Federal, State and local record keeping and reporting requirements, please provide the information requested for each household member. This information is needed for statistical purposes. Thank you. The LDCHA bans smoking inside all the units it owns. This includes all units at Edgewood Homes, Babcock Place, Peterson Acres I and II, Clinton Place and Scattered Sites. Smoking is permitted outside units on porches and balconies. This ban is strictly enforced and violations will lead to termination of housing.

Head of Household: Name: _________________________________________________ any other names used: __________________________________

Residential Address (Where you live): ____________________________________________________________________________

City: _______________________________________________ State: _____________________ Zip Code: ___________________

Mailing Address (Where you want your mail sent): _________________________________________________________________


Home phone: _____________________________ Work phone: ______________________________________________________

Cell Phone_______________________________ E-mail Address: ____________________________________________________

Military Status: ___________________________ Social Security Number: _____________________________________________

Date of Birth: ___________________ Place of Birth: ______________________________________________________________

Sex Race Ethnicity Marital Status Citizenship

Race: White; Black/African American; American Indian/Alaskan Native; Asian; Native Hawaiian/Pacific Islander; Mixed Ethnicity: Hispanic/Latino; Not Hispanic/Latino If not a U.S. citizen, Immigration status and Alien Registration Number: __________________________________________________ Require wheelchair or other accessibility features: � Yes � No Require live-in attendant care: � Yes � No Attendant’s Name: _____________________________________ Spouse/Other Adult: Name: ____________________________________________________ Relation to Head of Household: ______________________

Home phone: _____________________________ Work phone: ______________________________________________________

Cell Phone_______________________________ E-mail Address: ____________________________________________________

Military Status: ___________________________ Social Security Number: _____________________________________________

Date of Birth: ___________________ Place of Birth: ______________________________________________________________

Sex Race Ethnicity Marital Status Citizenship

Race: White; Black/African American; American Indian/Alaskan Native; Asian; Native Hawaiian/Pacific Islander; Mixed Ethnicity: Hispanic/Latino; Not Hispanic/Latino If not a U.S. citizen, Immigration status and Alien Registration Number: _________________________________________________ Require wheelchair or other accessibility features: � Yes � No

Require live-in attendant care: � Yes � No Attendant’s Name: _______________________________________________________ Initial: ___________

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Other Household Members – (Attach additional page if needed):

*List all persons who will live with you under housing assistance

Name: ____________________________________________________ Relation to Head of Household: ______________________

Social Security Number: ____________________________________

Sex Race Ethnicity Date of Birth Place of Birth


Require live-in attendant care: � Yes � No Attendant’s Name: _______________________________________________________











If both parents of minors listed above are not members of the household, you must report the name and address for each parents who is not a household member.

Name & Address of parents not listed above for each minor in the household: Name: _____________________________________________________________________________________________________

Residential Address (Where they live): ____________________________________________________________________________


Name: _____________________________________________________________________________________________________

Residential Address (Where they live): ____________________________________________________________________________


Initial: ___________

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Household Information

1. Will anyone else live in the unit on either a full-time or part-time basis, such as children temporarily absent, children in a joint custody arrangement, children away at school, unborn children, children in the process of being adopted, or temporarily absent family members? Yes No

If YES, explain

2. Do you expect the number of household members to change in the future? Yes No If YES, explain how many members will be added or reduced, and when that change will take place. __________________________________________________________________________

3. Have any of the household members used names or a social security number other than the names and numbers used above? Yes No

If YES, explain

Income For all people in the household, list each type of income, the address of the source of the income, and the monthly gross amount before any deductions. Income is money from any source received in the form of checks, cash, or credit toward an account.

SOURCE/TYPE OF INCOME HOUSEHOLD MEMBER PAID

NAME & ADDRESS OF SOURCE (STREET/CITY/STATE)

MONTHLY AMOUNT

Employment Income

Unemployment Benefits

Worker’s Compensation

Child Support/Alimony

Food Stamps

DCF (SRS) Cash Assistance

Social Security/ SSI

Pension/Annuity/VA Benefits

Cash Contributions

Interest/Dividend Income

Tribal Allotments/Payments

Student Financial Aid

Initial: ___________

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Earned Income: List all employment income for all household members including children: Employer 1:

Household Member Employed:

Employer’s Name: Employer’s Phone #: ( )

Address of Employer:

City: State: Zip Code:

Occupation/title: Years Employed: Gross Per Month: $

Employer 2:

Household Member Employed:

Employer’s Name: Employer’s Phone #: ( )

Address of Employer:

City: State: Zip Code:

Occupation/title: Years Employed: Gross per Month: $

Use additional page if needed

ANSWER THE FOLLOWING QUESTIONS ABOUT ALL MEMBERS OF THE HOUSEHOLD, INCLUDING CHILDREN

IS ANY MEMBER OF YOUR HOUSEHOLD

Yes___ No___ Working full-time or part-time? If yes, list all employers on earned income page.

Yes___ No___ Expecting to work for any period of time during the next year?

Yes___ No___ Working for someone who pays cash? If yes, list all sources on earned income page.

Yes___ No___ Expecting a leave of absence from work due to lay-off, medical, maternity, military or

Any other type of leave? If yes, please provide written verification.

Yes___ No___ Now receiving or expecting to receive unemployment benefits? If yes, provide a printout of benefit letter.

Yes___ No___ Now receiving or expecting to receive child support? If yes, provide printout of amounts received.

Yes___ No___ Entitled to child support but not currently receiving?

Yes___ No___ Now receiving or expecting to receive alimony/spousal support? If yes, provide copy of amounts received.

Yes___ No___ Entitled to receive alimony or spousal support but not currently receiving?

Yes___ No___ Now receiving or expecting to receive cash benefits from SRS? If yes, provide copy of benefit letter.

Yes___ No___ Now receiving or expecting to receive food stamps from SRS? If yes, provide copy of benefit letter.

Yes___ No___ Now receiving or expecting to receive any benefits from the Social Security Administration including SS, SSI or SSDI

Benefits? If yes, provide copy of the most recent benefit letter. (Include all pages sent from Social Security.)

Yes___ No___ Now receiving or expecting to receive income from pension or annuity? If yes, provide copy of benefit letter.

Yes___ No___ Now receiving or expecting to receive regular contributions from organizations or from individuals not living in the unit.

If yes, provide notarized statement of amounts received.

Yes___ No___ Now receiving or expecting to receive tribal allotments? If yes, provide a copy of the last two allotment statements.

Yes___ No___ Now receiving or expecting to receive income from assets including interest or dividends on checking accounts, certificates of deposit, savings accounts, stocks, bonds or mutual funds? If yes, provide the most recent copies of statements.

Yes___ No___ Own a home or have owned a home in the last three years? If yes, provide copy of tax return or settlement if property sold.

Yes___ No___ Does any household member own rental property or receive income from rental property?

Yes___ No___ Has any household member sold or given away real property or other assets (including cash) in the past two (2) years?

Yes___ No___ Is any member of your household age 18 or over a full-time student? If yes, provide proof of student

Initial: ___________

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FINANCIAL ASSETS: (ALL ADULTS MUST COMPLETE THIS SECTION) (use additional pages if necessary) Describe and give the current value to all assets. Write “none” on the line if you do not have that type of asset. Checking Account _____________________________________________________________________$____________ Name of Bank Balance Checking Account _____________________________________________________________________$____________ Name of Bank Balance Savings Account ______________________________________________________________________$____________ Name of Bank Balance Savings Account ______________________________________________________________________$____________ Name of Bank Balance Stocks/Bonds/Trusts ____________________________________________________________________________$______________ Name, Number & Maturity Date Value Stocks/Bonds/Trusts ____________________________________________________________________________$______________ Name, Number & Maturity Date Value Other Assets ____________________________________________________________________________$______________ Describe Value Has any household member disposed of any asset or property for less than fair market value during the past two (2) years? YES NO (circle one) If yes, please complete the form included in this packet. Only if no income is reported, initial here to certify that you receive ABSOLUTELY NO income:________ Warning: Section 1001 of title 18 of the United States codes makes it a criminal offense to make willful, false statements or misrepresentation to any department or agency of the United States as to any matter within its jurisdiction. Under Federal Regulations the Lawrence-Douglas County Housing Authority is charged with determination and verification of complete household income for all persons receiving or applying for housing assistance. Failure to supply requested income information that is true, accurate and complete is grounds for denial and/or termination of housing assistance and may lead to a debt for overpayment of housing assistance and to prosecution for criminal fraud against the housing authority Initial: ___________

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Failure to disclose all previous assisted housing and/or criminal history for any household member will result in denial of eligibility.

Previous Assisted Housing Has ANY household member ever lived in any type of federally subsidized housing? � YES � NO

If YES, list below:

Former Address: City: State: _____ Zip: _______

Housing Authority/Agency’s Name: Date moved in: _____________ Date moved out:

Does ANY household member owe a debt to this or any housing program housing program? � YES; � NO.

If YES, have arrangements been made to pay it back? � YES � NO

Criminal History 1. Has ANY household member ever been charged with a crime OR arrested, even if not charged? � YES � NO 2. Is ANY household member required to register with any State as a sex offender? � YES � NO 3. Has ANY household member been convicted of manufacture or sale of methamphetamine? � YES � NO 4.

If you answered YES to any of the above questions explain on lines below by giving the question number, date, charges, and court where charges were filed.

Example: #1 12/01/1998 DUI Lawrence, KS

Please go over this form and be sure it is filled in completely. Incomplete Applications will not be processed.

CERTIFICATION (All adults must sign)

I/we certify that the information given to the Lawrence-Douglas Housing Authority on this Application is accurate and complete to the best of my/our knowledge. I/we understand that false statements or information is punishable under Federal Law and is grounds for denial of eligibility, termination of housing assistance and termination of tenancy. Under of penalty of perjury I/we do hereby certify to the information provided in this Personal Declaration. Signature of Head of Household: Date:

Signature of Other Adult Member: Date:

How Did You Hear About LDCHA? _________________________________________________________

All correspondence will be sent to the applicant head of household at the mailing address provided unless a written authorization signed by the applicant is submitted to the LDCHA allowing communication with another person or agency on behalf of the applicant.

NOTE TO APPLICANT: If you believe you have been discriminated against, you may call the Fair Housing and Equal Opportunity National Toll Free Hot Line (800) 424-8590

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CERTIFICATION OF ASSETS DISPOSED OF FOR LESS THAN FAIR MARKET VALUE

This form must be signed by the applicant

I hereby certify that during the two year (24 month) period preceding the effective date of my examination of eligibility I have not disposed of any assets(s) for less than fair market value.

I hereby certify that during the two year (24 month) period preceding the effective date of my examination of

eligibility I have disposed of the assets(s) for less than fair market value. The asset(s) I/we disposed of was: The value of the assets(s) I/we disposed of was: The amount(s) received for the asset(s) I/we disposed of was: Warning: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Department or Agency of the United States as to any matter within its jurisdiction. Under penalty of perjury I/we do hereby certify to the information provided in this Certification of Assets Disposed for Less than Fair Market Value. ________________________________________ _________________________________ Signature of Tenant/Applicant Date

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OMB Control # 2502-0581 Exp. (07/31/2012)

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 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:

Mailing Address: Telephone No: Cell Phone No:

Name of Additional Contact Person or Organization: Address: Telephone No: Cell Phone No: E-Mail Address (if applicable): Relationship to Applicant: Reason for Contact: (Check all that apply)

Emergency Unable to contact you Termination of rental assistance Eviction from unit Late payment of rent

Assist with Recertification Process Change in lease terms Change in house rules Other: ______________________________

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.

Check this box if you choose not to provide the contact information.

Signature of Applicant Date

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.

Form HUD- 92006 (05/09)

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DECLARATION OF SECTION 214 STATUS The Lawrence-Douglas County Housing Authority must verify citizenship or immigration status for each household member. In Column A of the chart below list all persons who live or will live in the assisted rental unit, starting with the head of household. In Column B list the city, state and country where they were born. In Column C list their immigration status. A list of eligible immigration criteria follows the chart. All non-citizens must provide a copy of their immigration documents with their application for housing assistance. Applicants claiming eligible immigration status will be asked to sign a verification consent form and the LDCHA will request DHS verification of the claimed status.

All household members age 18 and over must sign this form. The head of household may sign for children in the household.

COLUMN A HOUSEHOLD MEMBERS (FIRST, MIDDLE & LAST NAMES)

COLUMN B

PLACE OF BIRTH (CITY, STATE, COUNTRY)

COLUMN C IMMIGRATION STATUS

ELIGIBLE IMMIGRATION STATUS CRITERIA NUMBERS

(Enter in COLUMN C above if person was not born a United States Citizen) 1. Immigration status under SS101(a) (15) or 101(a) (30) of the Immigration and Naturalization Act (INA) A noncitizen lawfully

admitted for permanent residence, as defined by §101(a)(20) of the Immigration and Nationality Act (INA), as an immigrant, as defined by §101(a)(15) of the INA (8 U.S.C. 1101(a)(20) and 1101(a)(15), respectively [immigrant status]. This category includes a noncitizen admitted under §§210 or 210A of the INA (8 U.S.C. 1160 or 1161), [special agricultural worker status], who has been granted lawful temporary resident status.

2. Permanent residence under S249 of INA. A noncitizen who entered the U.S. before January 1, 1972, or such later date as enacted by law, and has continuously maintained residence in the U.S. since then, and who is not ineligible for citizenship, but who is deemed to be lawfully admitted for permanent residence as a result of an exercise of discretion by the Attorney General under §249 of the INA (8 U.S.C. 1259) [amnesty granted under INA 249].

3. Refugee, asylum, or conditional entry status under SS207, 208 or 203 of the INA. A noncitizen who is lawfully present in the U.S. pursuant to an admission under §207 of the INA (8 U.S.C. 1157) [refugee status]; pursuant to the granting of asylum (which has not been terminated) under §208 of the INA (8 U.S.C. 1158 [asylum status]; or as a result of being granted conditional entry under §203(a)(7) of the INA (U.S.C. 1153 (a)(7)) before April 1, 1980, because of persecution on account of race, religion, or political opinion or because of being uprooted by catastrophic national calamity [conditional entry status].

4. Parole status under SS213(d) (5) of the INA. A noncitizen who is lawfully present in the U.S. as a result of an exercise of discretion by the Attorney General for emergent reasons or reasons deemed strictly in the public interest under §212(d)(5) of the INA (8 U.S.C. 1182(d)(5)[parole status].

5. Threat to life or freedom under S243(h) of the INA. A noncitizen who is lawfully present in the U.S. as a result of the Attorney General’s withholding deportation under §243(h) of the INA (8 U.S.C. 1253(h) [threat to life or freedom].

6. Amnesty under S245A of the INA. A noncitizen lawfully admitted for temporary or permanent residence under §245A of the INA (8 U.S.C. 1255a)[amnesty granted under INA 245A].

I the undersigned do hereby certify, under penalty of perjury that, to the best of my knowledge, the members of my household are citizens of the United States or have the immigration status listed above.

SIGNATURE OF HEAD OF HOUSEHOLD DATE SIGNATURE OF Spouse or other Adult DATE SIGNATURE OF Other Adult DATE

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LAWRENCE-DOUGLAS COUNTY HOUSING AUTHORITY

Citizenship Verification Consent Form

INSTRUCTIONS: Make as many copies as needed. Complete a separate form for each noncitizen family member who declared eligible immigration status. Attach evidence of immigration status. If this form is being completed on behalf of a child, it must be signed by the adult responsible for the child. CONSENT I, _________________________________________________ hereby consent to the following: (print or type first name, middle initial, last name) The use of the attached evidence to verify my eligible immigration status to enable me to receive financial assistance for housing; and

1. 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 the following:

a. HUD, as required by HUD; and b. The DHS for purposes of verification of the immigration status of the individual.

NOTIFICATION TO FAMILY: Evidence of eligible immigration status shall be released only to the DHS 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 DHS. Signature_____________________________________ Date__________________ Check here if adult signed for a child:

Original is retained by the requesting organization. ref. Handbooks 7420.7, 7420.8, & 7465.1

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

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

PHA-owned rental public housingTurnkey III Homeownership OpportunitiesMutual Help Homeownership OpportunitySection 23 and 19(c) leased housingSection 23 Housing Assistance PaymentsHA-owned rental Indian housingSection 8 Rental CertificateSection 8 Rental VoucherSection 8 Moderate Rehabilitation

Failure to Sign Consent Form: Your failure to sign the consentform may result in the denial of eligibility or termination ofassisted housing benefits, or both. Denial of eligibility or termi-nation of benefits is subject to the HA’s grievance procedures andSection 8 informal hearing procedures.

Sources of Information To Be ObtainedState Wage Information Collection Agencies. (This consent islimited to wages and unemployment compensation I have re-ceived during period(s) within the last 5 years when I havereceived assisted housing benefits.)

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

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

Information may also be obtained directly from: (a) current andformer employers concerning salary and wages and (b) financialinstitutions concerning unearned income (i.e., interest and divi-dends). I understand that income information obtained from thesesources will be used to verify information that I provide indetermining eligibility for assisted housing programs and the levelof benefits. Therefore, this consent form only authorizes releasedirectly from employers and financial institutions of informationregarding any period(s) within the last 5 years when I havereceived assisted housing benefits.

Authority: Section 904 of the Stewart B. McKinney HomelessAssistance Amendments Act of 1988, as amended by Section 903of the Housing and Community Development Act of 1992 andSection 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 verifi-cation of salary and wages from current or previous employers; (2)HUD and the HA to request wage and unemployment compensa-tion claim information from the state agency responsible forkeeping that information; (3) HUD to request certain tax returninformation from the U.S. Social Security Administration and theU.S. Internal Revenue Service. The law also requires independentverification of income information. Therefore, HUD or the HAmay request information from financial institutions to verify youreligibility and level of benefits.

Purpose: In signing this consent form, you are authorizing HUDand the above-named HA to request income information from thesources listed on the form. HUD and the HA need this informationto verify your household’s income, in order to ensure that you areeligible for assisted housing benefits and that these benefits are setat the correct level. HUD and the HA may participate in computermatching programs with these sources in order to verify youreligibility and level of benefits.

Uses of Information to be Obtained: HUD is required to protectthe income information it obtains in accordance with the PrivacyAct of 1974, 5 U.S.C. 552a. HUD may disclose information(other than tax return information) for certain routine uses, such asto other government agencies for law enforcement purposes, toFederal agencies for employment suitability purposes and to HAsfor the purpose of determining housing assistance. The HA is alsorequired to protect the income information it obtains in accordancewith any applicable State privacy law. HUD and HA employeesmay be subject to penalties for unauthorized disclosures or im-proper uses of the income information that is obtained based on theconsent form. Private owners may not request or receiveinformation authorized by this form.

Who Must Sign the Consent Form: Each member of yourhousehold who is 18 years of age or older must sign the consentform. Additional signatures must be obtained from new adultmembers joining the household or whenever members of thehousehold become 18 years of age.

PHA requesting release of information; (Cross out space if none) IHA requesting release of information: (Cross out space if none)(Full address, name of contact person, and date) (Full address, name of contact person, and date)

U.S. Department of Housingand Urban DevelopmentOffice of Public and Indian Housing

Original is retained by the requesting organization. ref. Handbooks 7420.7, 7420.8, & 7465.1

Signatures:

_____________________________________________ ______________Head of Household Date

___________________________________________Social Security Number (if any) of Head of Household

__________________________________________________ _______________Spouse Date

__________________________________________________ _______________Other Family Member over age 18 Date

__________________________________________________ _______________Other Family Member over age 18 Date

Consent: I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form forthe purpose of verifying my eligibility and level of benefits under HUD’s assisted housing programs. I understand that HAs thatreceive income information under this consent form cannot use it to deny, reduce or terminate assistance without firstindependently verifying what the amount was, whether I actually had access to the funds and when the funds were received. Inaddition, I must be given an opportunity to contest those determinations.

This consent form expires 24 months after signed.

__________________________________________________ ________________Other Family Member over age 18 Date




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 penalties for unauthorized disclosures or improper uses ofinformation 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 knowingly or willfullyrequests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not morethan $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, againstthe officer or employee of HUD, the HA or the owner responsible for the unauthorized disclosure or improper use.

Privacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this informationby 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 FairHousing Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants andparticipants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income andother information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your familywill pay toward rent and utilities. Other Uses: HUD uses your family income and other information to assist in managing and monitoringHUD-assisted housing programs, to protect the Government’s financial interest, and to verify the accuracy of the information you provide.This information may be released to appropriate Federal, State, and local agencies, when relevant, and to civil, criminal, or regulatoryinvestigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permittedor required by law. Penalty: You must provide all of the information requested by the HA, including all Social Security Numbers you,and all other household members age six years and older, have and use. Giving the Social Security Numbers of all household memberssix years of age and older is mandatory, and not providing the Social Security Numbers will affect your eligibility. Failure to provideany of the requested information may result in a delay or rejection of your eligibility approval.

Paperwork Reduction Notice: Public reporting burden for this collection of information is estimated to average 7 minutesper response. This includes the time for respondents to read the document and certify, and any recordkeeping burden. Thisinformation will be used in the processing of a tenancy. Response to this request for information is required to receivebenefits. The agency may not collect this information, and you are not required to complete this form, unless it displaysa currently valid OMB control number. The OMB Number is 2577‐0266, and expires 08/31/2016.

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 at 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 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 charges such as damages, utility charges, etc.); and

2. Whether or not you have entered into a repayment agreement for the amount that 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 judgment 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., abandoned unit, fraud, lease

violations, criminal activity, etc.) as of the end of participation date.

U.S. Department of Housing and Urban Development Office of Public and Indian Housing

DEBTS OWED TO PUBLIC HOUSING AGENCIES AND TERMINATIONS

OMB No. 2577-0266 Expires 08/31/2016

08/2013 Form HUD-52675

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.

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 908and 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 bemade 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, when you provide the PHA with documentation of your bankruptcy status.

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:

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

Signature Date

Printed Name

OMB No. 2577-0266 Expires 08/31/2016

08/2013 Form HUD-52675

03-2014 17

Residential History Worksheet List where you lived or stayed for the past 3 years. Do not leave out any places you stayed or leave any time during the past 3 years unaccounted for. Contact information for all landlords and persons you stayed with must be provided.

Landlord’s Name/Address Your Address Dates 1. From: To:

Own Rent With family/friends Phone: Name and relationship to you of person you lived/stayed with: Phone Number for this person:

Landlord’s Name/Address Your Address Dates

2. From: To:



3. From: To:



4. From: To:



5. From: To:



6. From: To:


________________________________________ _________________________________ Signature of Tenant/Applicant Date

03-204 18

Residential History Worksheet List where you lived or stayed for the past 3 years. Do not leave out any places you stayed or leave any time during the past 3 years unaccounted for. Contact information for all landlords and persons you stayed with must be provided.

Landlord’s Name/Address Your Address Dates 1. From: To:



2. From: To:



3. From: To:



4. From: To:



5. From: To:



6. From: To:


________________________________________ _________________________________ Signature of Tenant/Applicant Date

03-2014 19

LAWRENCE-DOUGLAS COUNTY HOUSING AUTHORITY

AUTHORIZATION FOR RELEASE OF INFORMATION

ALL ADULTS (18 & OVER) LIVING IN THE RENTAL UNIT MUST READ & SIGN THIS FORM PURPOSE The Lawrence-Douglas County Housing Authority (LDCHA), hear in after referred to as “housing authority”, may use this authorization, and the information obtained with it, to administer and enforce program rules and policies. AUTHORIZATION I/we authorize the release of any information, including documentation and other materials, necessary to verify eligibility for or participation under any housing assistance program administered by the housing authority. I/we authorize the housing authority to obtain information about me or my family that is pertinent to the determination of my eligibility for or participation in assisted housing programs, my level of benefits and verification of the true circumstances concerning myself and all members of my household. I/we agree that photocopies of this authorization may be used for the purpose stated herein. INQUIRIES MAY BE MADE ABOUT

Child Care Expenses Handicapped Assistance Expenses Credit History Identity and Marital Status Criminal History and Activity Law Enforcement Records Probationary Records

Family Composition Social Security Numbers Employment, Income, Pensions and Assets Employment Services Residences and Rental History Federal, State, Tribal or Local Benefits Community Support Assistance

Medical Expenses Welfare Services Educational, vocational and training services Social Services

INDIVIDUALS OR ORGANIZATIONS THAT MAY RELEASE INFORMATION INCLUDE Banks and Other Financial Institutions Local/State/Federal Courts Local/State/Federal Law Enforcement Agencies Credit Bureaus Employers, Past and Present Schools and Colleges Landlords Local Community Social Service Agencies Utility Companies State Welfare Agencies

Providers of: Alimony Child Care Child Support Credit Disability and/or Handicapped Assistance Medical Care/Services Pensions/Annuities Mental Health Services Substance Abuse Treatment

CONDITIONS I/we agree that permission to release information for the purposes stated above will remain in effect as long as I/we remain a participant in LDCHA housing programs or a resident in a LDCHA rental unit. A new release will be signed each year and whenever there is a change in the adult membership of the household. I/we understand that failure to sign this authorization may be grounds for housing assistance to be denied, delayed or terminated.

I/we voluntarily waive all right of recourse and release each such person from liability for providing information to the LDCHA. PRINT NAME: SOC SEC. # DATE OF BIRTH ADDRESS SIGNATURE DATE _____________________________

PRINT NAME: SOC SEC. # DATE OF BIRTH ADDRESS SIGNATURE DATE

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