FORT WALTON BEACH HOUSII{G AUTHORITY27 Robinwood Drive, SW

Fort Walton Beach, Florida 32548(8s0) 243-3224 Fax/TDD (8s0) 244-6533 TTY (850) 243-244s

Website: fwbha.com Email: Fwbha@fwbha.org

Gail SansburyExecutive Director

Public Housing Application

Dear Applicant:

Thank you for completing an application for Public Housing through the Fort Walton Beach HousingAuthority.

You will be placed on the waiting list based on the information that you provide to us on the attachedapplication. The selection process is based on the date and time of your application; therefore, theremay be other applicants ahead of you on the waiting list. We do not have emergency housing, nor canyou get preference over anyone else on the waiting list. You will be contacted by mail when your namecomes to the top of the waiting list.

Based on our curtent policy, current Public Housing residents are required to fulfill a two-year leasebefore they are eligible for the Section 8 program.

If you should have a change of address, telephone number and /or family size, please bring thechanges to the office in writing. Failure to report a change of address may result in ourcoffespondence being returned and you being unable to contact us within the designated timespecified on a letter. If you do not respond to us within the designated time, your application will beplaced in the inactive files. Once your file is designated inactive, you will be required to reapply.

Again, thank you for completing an application and we look forward to assisting you with yourhousing needs.

I do hereby understand and agree to the process of being placed on the Public Housing waiting list andif you're mailing address changes to bring it to the office in writing.

lf you haye any questions, please contact this office at (850) 243-3224

EOUAT HOUgIHGOPPORTUHIIT

Revised 9/2014

We thank you for your application and need to make sure you understand the following:

1. Do not fax this application.

2. Must be original documents. Gopies will be made at our office.

3. Print your name & address clearly.

4. You must provide ALL the information listed on the checklist before your application is considered

complete. lf you application is missing support documentation you will have 10 days from the date

of your application to bring all support documentation if you failed to provide required documentation

within the time frame, your application will be removed and you will be required to reapply.

5. You will be placed on the waiting list according to the date and time your application is turned in.

6. We do not have emergency housing, nor can you get a preference over anyone else on the waiting

list.

7. While you are on the waiting list, you must report changes in your income or family composition.

8. You must keep your mailing address updated at alltimes. lf we can't contact you by mail, your name

may be removed from the waiting list.

L lf you have lived in Public Housing or if you have had Section 8, you must tell us when and where.

Failure to tell us is fraud and your application will be removed from the waiting list.

10. ln the event you want to add an additional person to the application, the request must be in writing

no less than 45 days prior voucher issuance. The additional person is subject to all eligibility

requirements.

'l 1 . ln the event you request that a member of the household age 18 or older be removed, that member

will be required to request removal in writing and provide proof of residency elsewhere.

Revised 912014

The following is a list of documentation you must provide in order to apply for Public

Housing:.1 . original valid picture l.D. for any member 1B years or older.

2. Original Social Security cards for all family members.

3. Original Birth Certificates for all family members'

4. Most recent checking & savings account statements.

S. lnformation on any property you may own or have sold within the past 2years.

6. Proof of medical bills if you are elderly, disabled or handicapped.

7. lf you pay childcare we need a statement from the Childcare Facility on their letterhead with the

exact amount of expenses you pay each week'

g. lf your relative (mother, sister, grandmother) watches your child we need a notarized statement of

how much you PaY them.

9. Verification of all income for every family member. ( must be current)

. lf you are paid weekly we need 6 pay stubs, if you are paid bi-weekly we need 3 pay

stubs.

. Social Security Benefits, SSl, Pension, V.A. etc

. Unemployment

. lf your relative (mother, sister, grandmother, etc) gives you money for assistance we need a

notarized statement of much they give you.

10. Previous year's income tax return'(tax form 1040)

11. Proof of child support; either a court order or court history.

12. lf you receive alimony, we need a copy of the court order.

13. lf you receive AFDC (cash assistance) or Food Stamps we need a copy of the letter'

14. lf you have school-aged children, we need a proof of enrollment for the current year.(no report

cards/Prog ress rePo rt)

15.Copy of divorce decree (with financial arrangements), if applicable.

Revised 912014

Fort Walton Beach Housing Authority27 Robinwood Drive SW* Fort Walton Beach, Florida 32548

850-243-3224 . Fax 850-244-6533 . TTY 850-243-2445

Website: fwbha.com . Email: Fwbha@fwbha.org

Name Date

You have just placed an application with the Fort Walton Beach Housing Authority. The HA currently only

has 124 units which are located behind the office. Rent is based on income.

Once your application is approved and there is a unit available, the HA will notify you by mail. You will have

5 days from the date of your notice to respond to the HA if you are interested in the unit. At that time, you

will need the following.

1. You must be able to have power (electric) turned on in your name here in this local area prior to

moving in.

2. You will need a Security Deposit. (deposit is determent by your income)

3. First month's rent is pro-rated if your move-in date is after the 1"1. of the month.

4. Once the case manager determines rent you can offer Flat rent or lncome based depending on your

income and what is most beneficial for you at time of move in.

5. Community Services Hours. Everybody over the age 18 is required to do 8 hours a month on

community service if you are not working a minimum of 30 hours a week, enrolled in school full time

or receiving cash assistance. The only person exempt from community hours are elderly or disable.

I have received page 1,2,9, and copy of page 4 of this application, l'm aware of the process to be placed

on waiting list, l'm also aware of all changes in income and in family composition must be reported to this

office in writing within 10 business days of occurrence.

lf you should have a change of address, please bring changes to the office in writing.

Applicant Name & Date PHA Representative & Date

Revised 9/2014

You must use the correct

Fort Walton Beach Housing AuthorityPublic Housing Application

legal name for each member of your household as it appears on their Social Security Card.

cit

mem rhe i them i

Applicant Name SS#

Address Apt.Statehow

Zip Code

Telephone (H) (w) long at this address?

Marital Status tr single E Married E Separated E Divorced US Citizen: X Yes tr No

1. Household Com ition: List all who will be livi r home. List head of household first.

2. Race of Head of Household: ( Check one-used for statistical purpose only)

I White n Black I America Indian/Alaskan Native f, Asian E Native Hawaiian/other

3. Ethnicity of Head of Household: (statistical purpose only) n Hispanic/Latino E Non Hispanic

Child(ren's) absent Parent Child(ren's) absent parent

Address Address

Social Security # Social Security #

Date of Birth Date of Birth

Disable/Handicapped(Y) or (N)

Date of BirthRelationship to headof household

Legal names ofhousehold membersand maiden name ifapplicable

Revised 912014

HouseholdMember

o Is any adult family member employed? E Yes tr No if yes, name, address& phone # of employer:

o Is any family member receive one of the following:(Check all that apply) tr SSI I Disability tr SSA

o Are you presently in a Transitional Housing Program? E Yes n No

If so, which one?

Have you ever owned a home? n Yes tr No

Do you have Special Housing needs? E Yes tr No

Have you been lnvoluntarily Displaced? [ Yes tr No

Is the applicant family displaced by a declared Natural Disaster, such as a flood, hurricane, earthquake, etc'?

EYesINo

a

o

o

o

5. Backgroundlnformationa) Have you, or any adult member of your

than the one you are currently using? nfamily, ever used any name(s) or Social Security number(s) other

Yes E No if yes, exPlain below.

b) Have you, or any member of your household, lived in Public Housing and or Section 8 or any assisted

housing? n Yes n No (if yes, where, and when explain below. Do you owe a balance? n Yes tr No

c) H"* y*, * *y"* * ).ur household ever been convicted of any crime other than traffic violation?

! Yes I No if yes, exPlain below.

d) Have you ever commiited any fraud in a Federal assistance housing program or been requested to repay

*on"y for misrepresenting information? I Yes E No if yes, explain below

e) Do you own any assets? tr Real estate tr Checking Account n Savings Account X Cash Deposits

n Money Market tr Other

6. Have you sold anY real estate in the past two years? E Yes tr No if yes, what was the address?

7. Current Landlord's name and phone #

-

location-date the family moved to this

Revised 912011

8.

9.

10.

11.

12.

Have you ever been evicted from housing? tr Yes I No if yes, why?

f, *yor. in your household ever been arrested or convicted of a crime other than a traffic violation?

E yes n No if yes, please explain the nature of the problem and who was involved:

Is anyone in your household currently on parole or probation? n Yes tr No if yes, please explain:

Do you have any past due utility bills? E Yes tr No if yes, please describe and give amount owed:

Is the applicant family displaced by domestic violence? tr Yes X No if yes, who can verify this? Please

pHA will be contacting all former landlords for the last five years from the

date of application.

Authorization of Release of Information- Applicants acknowledged that all the above information and

staternent on the uppli.utl* for rental assistance are true and complete. Applicant(s) acknowledges that

false or omitted information herein may constitute grounds for rejection of this application; I hereby swear

and attest that all of the information above is true and correct. I also understand that all changes in the

income of any member of the household, as well as any changes in the household members, must be

reported to the Housing Authority. IN WRITING, WITHIN 10 BUSINESS DAYS.

Signature of Head of Household and Date Signature of CO. Head and Date

Signature of Other Adult and Date Signature of Other Adult and Date

Warning: 1g U.S.C. 1001 provides, among other things that whoever knowingly and willfully makes or

uses a document or writing containing false, fictitious or fraudulent statement or entry in any matter within

the jurisdiction of an deparlment or agency of the United States shall be fine no more than

$1O,OOO or imprisoned for no more than five (5) years of both'

Revised 912014

Personal Declaration

THIS FORM MUST BE COMPLETED IN YOUR OWN HANDWRITING, YOU MUST USE THE

CORRECT LEGAL NAME FOR EACH MEMBER OF YOUR HOUSEHOLD. ALL ADULT MEMBERS

OF THE HOUSEHOLD MUST SIGN BELOW CERTIFYING THE INFORMATION PERTAINING TO

THEM. PLEASE PRINT.

L Household composition: list all persons who will be living in your home'

head of household first.Adults (legal Name) Date of Birth Relationship to

Head ofHousehold

Social Security # Indicate if manied(m)Widowed (W)Separated (S)

Divorced (D)

Children Date of Birth Relationship tohead ofhousehold

School Name Absent Parent'sName

Absent Parent'sAddress

If separated or divorced, list name and address of spouse/ex-spouse as follow:

Name Name

Street Address Street Address

City, State, Zip City, State, Zip

S.S. # (if known)S.S. # (if known)

Revised 9/2014

PERSONAL DECLARATION FORM (cont'd)II. ALL HOUSEHOLD INCOME: List all money earned or received by everyone living in your household.

This includes money from Wages, Self-Employment, Child Support, Contributions, Social Security,

Disability payments, Workman's Compensation, Retirement Benefits, AFDC, Veterans Benefits, Rental

property lncome, Stock Dividends, lncome from Bank Accounts, Alimony, and all other sources.

HouseholdMember

Employer TotalWeeklyWages

AFDC Child SupportMonthlyamount.

SocialSecurityBenefitsamount.

UnemploymentBenefit amount

All otherIncome

III. ASSETS: If yes to any, list below. Do you or any household member own or have an interest in any real

estate, boat, and /or mobile home? Have you sold any real estate in the last two year?

-Do you

own any stocks or bonds?

- Do you have a savings accounts?

-if

yes, give bank, account

numbers and amounts?

-

Do you own a car?

-

Model/Year Tag No.

Do you own a second cat?

- Model/Year Tag No.

1. Does anyone outside of your household pay for any of your bills or give you money?

-

if yes, explain

herez. Have you or any other adult members ever used any name(s) or social security number(s) other than the one

you are currently using?

-

if yes, explain

3. Have you or any member lived in any assisted housing? if yes, list where and when

4. Have you or anyone in your household ever been convicted of any crime other than traffic violations?

-5. Have you ever committed any fraud in a Federal assisted housing program or been requested to repay money

for knowingly misrepresenting information for such housing programs? if yes, explain

I do herby swear and attest that all of the information above is true and correct. I also understand that all changes

in the income of any member of the household as well as any changes in the household members must be reported

to the Housing Authority in Writing lmmediately. Within 10 Business Days'

Signature of Head of Household Date Signature of Co-Head Date

Signature of other Adult Date

WARNING! TITLE 18, SECTION 1OO1 OF THE UNITED STATES OF CODE, STATES THAT A PERSON

IS GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT

STATEMENT TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES.

Revised 912014

REASONABLE ACCOMMODATION

NOTICE OF RIGHT TO REASONABLE ACCOMMODATION

lf you have a disability and you need:

1. A change in the rules or policies or how we do things that would make it easier for you to live and use

the facilities or take part in programs on site;

2. A change or repair in your unit or special type of unit that would make it easier for you to live and use

the facilities or take part in programs on site;

3. A change or repair to some other part of the housing site that would make it easier for you to live and

use the facilities or take part in programs on site'

4. A change in the way we communicate with you or give you information, you can ask for this kind of

change, which is called a REASONOBLE ACCOMMODATION.

lf you can show that you have disability and if your request is reasonable; if it is not too expensive; and if it is not

too difficult to arrange, we will try to make the changes for your request'

we will give you an answer within 14 days of your request unless there is a problem getting the information we

need or unless you agree to a longer time. we will let you know if we need more information or verification from

you or if we would like to talk to know you about other ways to meet your needs'

lf we turn down your request, we wiil explain the reasons and you can give us more information if you think that

will help. lf you need help in filling out a Reasonable Accommodation Request form, or if you want to give us

your request in some other way, we will help you'

lf you make such a request, you will need some evidence that the problem was caused by the disability and that

the plan is likely to work. lf it involves someone else, you need evidence that they will provide the assistance'

you will need your doctor, health care provider or other qualified individual to verify that your request: (1) is

related to your disability; and (2) would provide you with an equal opportunity to enjoy our housing programs or

that your disability restricts you from performing task'

WARNING TITLE 18 SECTION 1 OO1 OF THE UNITED STATES CODE, STATES THAT PERSON IS GUILTY OF A FELONY FOR KNOWINGLY AND

WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES'

I have read the above statement or had it read to me and do fully understand it'

Name

10

Date

Revised 9/2O14

HEA UAL HOUSI IIEOPFOETUHITY

RHE$@MABIE A8&@MMO$ATU@H RE@UE$T F@RM

1.

Ft. walton Beach Housing Authority is committed to the letter and spirit of the Fair Housing Act, which, among

other things, prohibits discrimination against persons with disabilities. In accordance with our statutory

responsibilities and management policies, we will make reasonable accommodations in our rules, policies,

practices, or services, when such opportunity to use and enjoy their housing communities. If you are requesting

such an accommodation, please fill out this form'

DATE OF REQUEST:

NAME OF HEAD OF HOUSEHOLD:

STREET ADRESS:

TELEPHONE NUMBER:

please describe the accommodation (exception to our usual rule or policy) that you are

requesting

Do you consider yourself to be disabled?

The Fair Housing Act defines disability as a physical or mental impairment that substantially limits one or

more major life activities. The Supreme Court has determined that to meet this definition a person must have

an impairment that prevents or severely restricts the person from doing activities that are of central

importance in most peoples' daily lives.

Please circle one YES NO

please describe how the requested accommodation is necessary for your use and enjoyment of

your apartment community'

Tenant Statement:

I certify that the information that I have provided is true and conect and, that failure to provide truthful or correct information is

subject to my termination of continued residency of this housing program'

2.

11

SIGNATURE OF HEAD OF HOUSEHOLD DATE

Revised 912014

Consent Form

Consent

I authorize and direct any Federal, State, or local agency, organization, business, or individual to release to the Fort Walton

Beach Housing Authority any information or materials needed to complete and verify my specification for participation, and/or

to maintain my continued assistance under the Section 8 Rental Rehabilitation, low income Public and Indian Housing, and/or

other housing assistance programs. I understand and agree that this authorization or the information obtained with its use may

be given to and used by the Department of Housing and Urban Development (HIID) in administering and enforcing program

rules and policies.

Information Covered

I understand that, depending on program policies and requirements previous or current information regarding me or my

household may be needed. Verification and inquiries that may be requested include but are not limited to:

Identification and Marital Status Employment,Income and Assets

Residence and Rental History Medical or Child Care allowances

Credit and Criminal ActivitY

I understand that this authorization cannot be used to obtain any information about me that is not pertinent to my eligibility for

and continued participation in a housing assistance program'

Group or Individual that mav be asked

The groups or individuals that may be asked to release the above information (depending on program requirements) include but

are not limited to:

previous landlord (including public Housing Agency), Past and Present employers, veterans Administration, welfare Agency,

Retirement Systems, Court and post offices, State Unemployment Agencies, Banks and other Financial Institutions, Schools and

Colleges, Social Security Administration, Credit providers and Credit Bureaus, Law Enforcement Agencies' Medical and Child

Care Providers, Utility Companies, Support and Alimony Providers'

Computer Matching Notices and Consent

I understand and agree that HUD or the Public Housing Authority may conduct computer matching programs to verify the

information supplied for my application or re-certification. If a computer match is done, I understand that I have a right to

notification of any adverse information found and a chance to disprove that information. HUD may in the course of its duties

exchange such automated information with other Federal, State, or local agencies, including but not limited to State

Employment, Security Agencies, Department of Defense, Office of Personnel Management, The U.S. Postal Service, The Social

Security Agency and State Welfare and Food Stamp Agencies'

Conditions

I agree that a photocopy of this authorization may be used for the purposes listed above. This authorrzatron

will stay in effect for a year and one month from the date signed.

Signature Head of Household Date Signature of SPouse Date

Signature of Other Adult Date Signature of Other Adult Date

12 Revised 9l2ol4

RENTAL HISTORY

Please provide complete street address of EVERY place you have lived within the past five (5) years, must have

telephone numbers and dates when you lived there.

If you have ever lived in Public Housing or if you have ever had Section 8, you must tell us when and where.

Failure to tell us is fraud and your application will be removed from the waiting list.

. Name of previous Housing Authority (if applicable) Phone #

Your previous Public Housing /Section 8 AddressDates you live there Do you owe money there? Were you Evicted?- if yes,

whv?

o Name of you current Landlord & Phone #Your previous Address Dates you live there

Did you pay rent? If yes, how much?

. Name of your previous Landlord & Phone #Your previous Address Dates you live there

Did you pay rent? lf yes, how much

o Name of your previous Landlord & Phone #Your previous Address Dates you live there

Did you pay rent? If yes, how much

o Name of your previousYour previous AddressDid you pay rent?

Landlord & Phone #Dates you live there

If yes. how much

t3 Revised 912014

APPLICANT/TENANT' S CERTIFICATIONGiving True and Complete Information

I certify that all the information provided on household composition, income, family assets and items for

allowances and deductions, is accurate and complete to the best of my knowledge.

Reporting Changes in Income or Household Composition

I know I am required to report changes in income and any changes in the bedroom size when a person

moves in or out of the unit. I understand the rules regarding guests/visitors and when I must report anyone

who is staying with me.

Reporting on Prior Housing Assistance

I certify that I have disclosed where I received any previous Federal housing assistance and whether or not

any money is owed. I certify that for this previous assistance I did not commit any fraud, knowingly

misinterpret any information, or vacate the unit in violation of the lease.

No Duplicate Residence or Assistance

I certify that the house or apartment will be my principal residence and will not obtain duplicate Federal

housing assistance while I am in this current program.

Cooperation

I know I am required to cooperate in supply all information needed to determine my eligibility, level of

benefits, or verify my true circumstances. Cooperation includes attending pre-scheduled meetings and

completing and signing needed forms. I understand failure or refusal to do so may result in delays,

termination or assistance or eviction.

Criminal and Administrative Actions for False Information

I understand that knowingly supplying false, incomplete or inaccurate information is punishable under

Federal or State criminal law. I understand that knowingly supplying false, incomplete, or inaccurate

information is grounds for termination of housing assistance and/or termination of tenancy.

Signature and Date of ALL Adults in Household

Date

Date

t4 Revised 912014

FORT WALTOI,{ BEACH HOUSD{G AUTHORITY27 Robinwood Drive, SW

Fort Walton Beach, Florida 32548(850) 243-3224 Fax/TDD (850) 244-6533

Gail SansburyExecutive Director

Authorization for Criminal Records/B ackground Release

PLEASE PRINTAdult #1

EGUAL HOUEIHGOPPORTUHITY

Name Date of Birth

Street Address Soc. Sec. #

Phone Number

City, State, Zip Race Sex

Adult #2Name Date of Birth

Street Address Soc. Sec. #

Phone Number

City, State, Zip Race Sex

To Whom It May Concern:

The above-named client(s) has applied for Housing Assistance. [n order to verifyAdmissions Eligibility, we are required to perform routine Criminal Background

Checks (One Strike You're Out). Below please acknowledge signed Authorization/Release of Information. The information you provide will be strictly confidential and

will be used solely for determining eligibility or continued program participation. Anyadditional assistance that you can provide will be most appreciated.

I do hereby authorize the Fort Walton Beach Housing Authority to conduct routineCriminal Background Checks for the purpose of determining admissions or continued

participation eligibil ity.

Signature Date Signature Date

Signature

15

Date Signature f)ate