housing authority of brevard county public housing online

Online Application Verification Package

HOUSING AUTHORITY OF BREVARD COUNTY PUBLIC HOUSING ONLINE APPLICATION VERIFICATION PACKAGE

Housing Authority of Brevard County (North)

584 Player Lane Merritt Island, FL 32953 Phone: (321) 775-1577

Housing Authority of Brevard County (South)

4000 Riverside Drive Unit #100 Satellite Beach, FL 32937

Phone: (321) 775-1586

Office Hours: Monday - Thursday 9:00 a.m. to 5:30 p.m.

QUALIFICATIONS:

You must be an adult, 18 years of age or older.

You must pass a criminal history check (if any family member has been arrested or convicted for drug-related, violent criminal activity, or is subject to sexual predator registration with the State Law Enforcement, you will be denied).

You must pass a landlord reference check (no evictions in the last 3 years) on all applicants age 18 years and older.

You must meet income guidelines.

IMPORTANT INFORMATION FOR YOU TO KNOW:

Please keep your mailing address and phone number current

in order for our office to reach you. If we are unable to update your file at the necessary time, you will be withdrawn and must re-apply.

We cannot accept an incomplete application.

We must have all the documents in order to process your application. We appreciate your attention to detail with this requirement

The Housing Authority of Brevard County provides equal opportunity to participate in our housing programs. Any persons with disabilities, as outlined by the Americans with Disabilities Act, requiring a reasonable accommodation to make this process accessible may request such by contacting the Client Customer Service Team. For the North area please call (321) 775-1577 and for the South area please call (321) 775-1586. The Housing Authority of Brevard County operates a site-based application and waitlist system and applicants should apply to the property (ies) where they desire to live.


HOUSING AUTHORITY OF BREVARD COUNY PUBLIC HOUSING ONLINE APPLICATION PROCEDURES

1. Fill out the attached verification documents. Please print clearly.

2. Additional adults must fill out additional forms. (All adults must also submit a copy of a Picture ID, Social Security Card, and proof of income.)

3. Bring or mail completed verification documents within 10 days to the Housing Authority of Brevard County management office that corresponds to the waiting list you are applying for (see your online application confirmation page for the appropriate address). If you are applying to more than one waitlist you MUST send verification documents to ALL addresses listed on your online confirmation page.

4. You will be notified if your application has been approved or denied. If approved, you will be required to sign additional paperwork at the time you move in.

Office Hours are Monday thru Thursday 9:00 a.m. to 5:30 p.m.

6. The Housing Authority of Brevard County will conduct a criminal record check, registered sex offender check, and landlord reference check on all applicants age 18 years and older.

7. Call (321) 775-0417 after 10 business days for your position on the waitlist.

8. Notify the Housing Authority of Brevard County of any changes within 10 days (phone number, address, income, family size) and update your application at least once every 12 months.

9. Notify the Housing Authority (in writing) if you wish to claim a preference or no longer qualify for a preference. If your family situation changes your ability to qualify for a preference may also change.

Each applicant who meets the above qualification will receive one unit of the size and type needed. If the applicant accepts the offer, the applicant will be offered a lease. If the applicant refuses the offer without good cause, the application will be withdrawn from the waiting list and the applicant will not be permitted to reapply for 12 months.

Pursuant to 24 CFR 960.206, HABC has adopted a preference for working families. An applicant will also be given the benefit of the working family preference if the head of household or spouse is elderly (62 or older) or is a person with disabilities. Applicants are placed on waiting lists according to any claimed preference first, following by date and time of application. Pursuant to Section 504 [24 CFR 8.4(b)(i), 8.24 and 8.33] and Fair Housing Act [24 CFP 100.204] Qualified individuals/families with disabilities may request Reasonable Accommodations to any rules, policies, practices or services when such accommodation is necessary to assure equal opportunity to the housing program(s) or dwellings.


HOUSING AUTHORITY OF BREVARD COUNTY PUBLIC HOUSING VERIFICATION DOCUMENT CHECKLIST

You MUST provide copies of the following verification documents

All documents MUST include online application confirmation number. within 10 days.

HOUSEHOLD MEMBER INFORMATION

Birth certificates, legal guardianship or eligible immigration verification of all household members

Social security cards for

all household members

Driver’s license or other photo ID for

Marriage license or divorce decree verification (affidavit may be used instead of divorce decree)

all members of household 18 years or older

HOUSEHOLD INCOME (include any expected income within the next 12 months)

Employment verification (provide the attached income verification form to your employer OR

VA, SS, SSI, AFDC, Food Stamps, and

three (3) consecutive paystubs

all other income

Child support or unenforceable support verification (court documents that outline current/future support amount and frequency)

verification (Provide printout of current/future support amount and frequency)

School enrollment verification for K-12, college, vocational training, and/or job training (current enrollment, class schedule or current transcript)

HOUSEHOLD ASSETS

Assets verification (including cash on hand, in banks, stocks, bonds, notes, Real Estate-Home, Trailer, Property, other personal property (i.e. gems, antiques), etc.

Bank statements verification (most recent three (3) monthly statements)

HOUSEHOLD EXPENSES

Child care expenses verification - Note: Per HABC ACOP: 6-II.A. ADJUSTED INCOME - (4) Any reasonable child care expenses necessary to enable a member of the family to be employed or to further his or her education. If applies, please provide statement on agency’s letterhead outlining child care expenses and frequency.

Medical expenses and insurance verification (elderly and persons with disabilities only)

OTHER VERIFICATIONS

Pregnancy verification (from medical facility or provider)

Special accommodations verification (from medical facility or provider)

Displacement due to domestic violence verification (court documents)

Displacement due to natural disaster verification (i.e. flood, hurricane, earthquake, etc.)

Veterans DD214 verification

Housing Authority of Brevard County (South) 4000 N. Riverside Drive, #100 Indian Harbour, Florida 32937 (321) 775-1583 (O) * (321) 773-9918 (F)

Melbourne Housing Authority 4000 N. Riverside Drive, #100 Indian Harbour, Florida 32937 (321) 775-1583 (O) * (321) 773-9918 (F)

Housing Authority of Brevard County (North) 584 Player Lane Merritt Island, Florida 32953 (321) 775-1577 (O) * (321) 704-8103 (F)

HABC Form Equal Housing – Equal Employment Page 1

NOTICE/DISCLOSURE AND ACKNOWLEDGMENT/RELEASE [IMPORTANT – PLEASE READ CAREFULLY BEFORE SIGNING]

NOTICE/DISCLOSURE REGARDING BACKGROUND INVESTIGATION

The Housing Authority of Brevard County may obtain information about you from a consumer reporting agency for tenant screening purposes. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living and which can involve personal interviews with sources such as your neighbors, friends, or associates. These reports may be obtained at any time after receipt of your authorization and, if a lease or rental agreement is initiated, throughout your occupancy. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of “consumer report” and/or an “investigative consumer report” obtained with regard to applicants for tenancy conducted by Edge Information Management, Incorporated, Post Office Box 3378, Melbourne, Florida 32902, 1-800-722-3343 consist of, but is not limited to, academic, residential, achievement, previous employment verification, professional licenses, credit reports, driving history, and criminal history records. The scope of this notice and authorization is all-encompassing, however, allowing the Housing Authority of Brevard County to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and, if you are hired, throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.

ACKNOWLEDGEMENT/RELEASE/AUTHORIZATION

I acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION and that I have read and understand this document. I understand that I may also have the right to request additional disclosures regarding the nature and scope of the investigation as well as the right to request a copy of A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT. If requested, the consumer reporting agency will explain the contents of my file. I understand that proper identification will be required and that I should direct my request to: Edge Information Management, Incorporated, Post Office Box 3378, Melbourne, Florida 32902. Phone 1-800-725-3343. FAX 1-800-780-3299. I hereby authorize the obtaining of “consumer reports” and/or investigative consumer reports: at any time after receipt of this authorization and, if a lease or rental agreement is initiated, throughout my occupancy. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Edge Information Management, Incorporated, another outside organization acting on behalf of the Housing Authority of Brevard County, and/or the Housing Authority of Brevard County itself. I agree that a facsimile (“fax”) or photographic copy of this Authorization shall be as valid as the original. I understand that the information requested below regarding date of birth, race and sex is for the sole purpose of gathering the above information accurately, and will not be used to discriminate against me in violation of any law.

READ, ACKNOWLEDGED AND AUTHORIZED – I authorize Edge Information to contact me at for clarification of any information provided.

Phone Number

Signature Print Name Date





Housing Authority of Brevard County NOTE: I am providing the following voluntarily. PLEASE PRINT CLEARLY NAME: First Middle (Full) Last Other Names Known By SOCIAL SECURITY#: - - DATE OF BIRTH (for ID purposes only) - - MO DAY YEAR SEX: RACE: DRIVER LIC#: STATE: CURRENT ADDRESS: CITY/STATE/ZIP: City State Zip PREVIOUS ADDRESS: CITY/STATE/ZIP: City State Zip

CERTIFICATION OF DOMESTIC U.S. Department of Housing OMB Approval No. 2577-0249 VIOLENCE, DATING VIOLENCE, and Urban Development Exp. (05/31/2007) OR STALKING Office of Public and Indian Housing

1 form HUD-50066 (11/2006)

Public reporting burden for this collection of information is estimated to average 1 hour per response. This includes the time for collecting, reviewing, and reporting the data. Information provided is to be used by PHAs and Section 8 owners or managers to request a tenant to certify that the individual is a victim of domestic violence, dating violence or stalking. The information is subject to the confidentiality requirements of the HUD Reform Legislation. This agency may not collect this information, and you are not required to complete this form unless it displays a currently valid OMB control number. Purpose of Form: The Violence Against Women and Justice Department Reauthorization Act of 2005 protects qualified tenants and family members of tenants who are victims of domestic violence, dating violence, or stalking from being evicted or terminated from housing assistance based on acts of such violence against them. Use of Form: A family member must complete and submit this certification, or the information that may be provided in lieu of the certification, within 14 business days of receiving the written request for this certification by the PHA, owner or manager. The certification or alternate documentation must be returned to the person and address specified in the written request for the certification. If the family member has not provided the requested certification or the information that may be provided in lieu of the certification by the 14th business day or any extension of the date provided by the PHA, manager and owner, none of the protections afforded to victims of domestic violence, dating violence or stalking (collectively “domestic violence”) under the Section 8 or public housing programs apply. Note that a family member may provide, in lieu of this certification (or in addition to it): (1) A Federal, State, tribal, territorial, or local police or court record; or (2) Documentation signed by an employee, agent or volunteer of a victim service provider, an attorney or a medical professional, from whom the victim has sought assistance in addressing domestic violence, dating violence or stalking, or the effects of abuse, in which the professional attest under penalty of perjury (28 U.S.C. 1746) to the professional’s belief that the incident or incidents in question are bona fide incidents of abuse, and the victim of domestic violence, dating violence, or stalking has signed or attested to the documentation. ___________________________________________________________________________________________ TO BE COMPLETED BY THE VICTIM OF DOMESTIC VIOLENCE: Date Written Request Received By Family Member: _______________________________________________ Name of the Victim of Domestic Violence: __________________________________________________________ Name(s) of other family members listed on the lease _________________________________________________ ______________________________________________________________________________________________ Name of the abuser: ____________________________________________________________________________ Relationship to Victim: _________________________________________________________________________ Date the incident of domestic violence occurred: ___________________________________________________ Time: _________________________________ Location of Incident: __________________________________________________________________________

form HUD-50066 (11/2006)

2

Name of victim: ____________________________________________________________________________________ Description of Incident: I hereby certify that the information that I have provided is true and correct and I believe that, based on the information I have provided, that I am a victim of domestic violence, dating violence or stalking and that the incident(s) in question are bona fide incidents of such actual or threatened abuse. I acknowledge that submission of false information relating to program eligibility is a basis for termination of assistance or eviction. Signature _______________________________________ Executed on (Date) __________________________________ All information provided to a PHA, owner or manager relating to the incident(s) of domestic violence, including the fact that an individual is a victim of domestic violence shall be retained in confidence by an owner and shall neither be entered into any shared database nor provided to any related entity, except to the extent that such disclosure is (i) requested or consented to by the individual in writing; (ii) required for use in an eviction proceeding or termination of assistance; or (iii) otherwise required by applicable law.

Description of Incident: [INSERT TEXT LINES HERE]

Housing Authority of Brevard County (South)

4000 N. Riverside Drive, #100

Indian Harbour, Florida 32937

(321) 775-1583 (O) * (321) 773-9918 (F)

Melbourne Housing Authority

4000 N. Riverside Drive, #100

Indian Harbour, Florida 32937

(321) 775-1583 (O) * (321) 773-9918 (F)

Housing Authority of Brevard County (North)

584 Player Lane

Merritt Island, Florida 32953

(321) 775-1577 (O) * (321) 704-8103 (F)


Income Verification

We are required by law to verify the income of all individuals living in or applying for Public Housing. We ask your

cooperation by supplying the information requested below about the referenced person. This information will be

held in confidence for use only in determining the family’s eligibility and rent.

We would greatly appreciate your prompt return of this letter. You may fax it to the number listed above or mail it to

the office address listed above.

Sincerely,

_______________________________

Management

I, ____________________ authorize the release of the information requested by the Housing Authority.

_______________________________

Tenant / Applicant signature

*********************************************************************************************

Employee Name:_______________________________________________________________________________

Address:______________________________________________________________________________________ City State Zip

Date employed:_________________ Date terminated / resigned:_______________________

Job Title:____________________________

Current Base Pay Rate:$___________ per hour, $________ per week, $__________ per month

Average hours worked at Base Pay Rate:__________ hrs/week, or __________hrs/month in year

Is this person likely to get Overtime? No Yes If yes, Overtime Pay Rate: $_____ hour

Average number of Overtime hours expected during the next 12 months: ___________hrs/month

Any other compensation not listed: Please specify for commissions, bonuses, tips, different pay, etc?

For:__________________ $_________________ per ____________________

Is increase in earnings anticipated? No Yes If yes, amount $___________ Eff. Date: ________________

Effective date of last increase: _________________________ Amount $ _____________________________

Total Gross pay (without overtime) earnings for the last 12 months: $___________________________

Total Overtime earnings for the last 12 months: $___________________________________________

Company Name: _______________________________________________________________________________

Address: _____________________________________________________________________________________

Phone: ______________________________ Fax:__________________________________

Name of Person Completing this Form: ___________________________________________

Date:_______________________________________

Title:_______________________________________

Signature: ___________________________________





Request and Authorization For Police Record Check

I, __________________________________, hereby authorize the Housing Authority of Brevard County Agency to complete and investigate my criminal background according to the “One Strike & You’re Out” Policy.

SIGNED: _________________________________

DATE: ___________________________________

PLEASE PRINT THE FOLLOWING:

NAME: _________________________________

DATE OF BIRTH: ________________________

SOCIAL SECURITY#: ____________________

Original is retained by the requesting organization. form HUD-9886 (7/94)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. form HUD-9886 (7/94)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 15 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.

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)





EXTRACT

STATE OF FLORIDA HOUSING AUTHORITIES LAW

CHAPTER 421.101

421.101 False representations to obtain lower rent in housing accommodations; penalty.--Whoever makes a false statement or representation, knowing it to be false, or knowingly fails to disclose a material fact in order to obtain a lower rent for housing accommodations in a low-rent housing development operated pursuant to this chapter, than the rental such person is required to pay pursuant to federal or state statutes, schedule of rents or rules and regulations as determined and fixed by housing authorities created pursuant to this chapter, aforesaid, shall be guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082 or s. 775.083; and each such false statement or representation or failure to disclose a material fact as aforesaid shall constitute a separate offense.

I (we) have read or had read to me (us) by HOUSING AUTHORITY OF BREVARD COUNTY Chapter 421.101, Housing Authorities Law of the State of Florida and understand its meaning and the penalties which may result from its violation. I (we) further understand that family income as defined in housing authority policy determines eligibility for low income housing and rent, and that any and all changes in family income must be reported to housing management immediately following the change.

I (we) further understand that all persons residing on the premises, excepting bona fide guests as defined in housing authority policy, must be reported to management at admission or immediately following any change in family composition. It is understood that all persons residing on the premises are considered family members. With this knowledge I (we) state that I (we) have reported to housing management all persons residing on the premises and all family income and that no family member received, receives, or expects to receive any other income from any source as of this day.

WITNESS: TENANT(S):

__________________________________ _______________________________Signature Signature Date: ____________________ Date:___________________________

http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=Ch0775/Sec082.HTM�

http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=Ch0775/Sec083.HTM�

DECLARATION OF SECTION 214 STATUS

NOTICE TO APPLICANTS AND TENANTS: In order to be eligible to receive the housingassistance sought, each applicant for, or recipient of, housing assistance must be lawfullywithin the United States. Please read the Declaration statement carefully, sign and return itto the Housing Authority office. Please feel free to consult with an immigration lawyer orother immigration expert of your choice.

I, _______________________________________, certify, under penalty of perjury 1/, that, tothe best of my knowledge, I am lawfully within the United States because (please checkappropriate box):

( ) I am a citizen by birth, a naturalized citizen, or a national of the United States; or

( ) I have eligible immigration status and I am 62 years of age or older. Attachevidence of proof of age 2/; or

( ) I have eligible immigration status as checked below (see reverse side of this formfor explanations). Attach INS document(s) evidencing eligible immigration statusand signed verification consent form.

[ ] Immigrant status under §§101(a)(15) or 101(a)(20) of the INA 3/; or

[ ] Permanent residence under 249 of INA 4/; or

[ ] Refugee, asylum, or conditional entry status under §§207, 208, or 203 of the INA 5/; or

[ ] Parole status under §§212(d)(5) of the INA 6/; or

[ ] Threat to life or freedom under §243(h) of the INA 7/; or

[ ] Amnesty under §245A of the INA 8/.

_______________________________________________ _______________________Signature of Family Member) Date

� Check box on left if signature is of adult residing in the unit who is responsible for childnames on statement above.

[See reverse side for footnotes and instructions]

HA: Enter INS/SAVE Primary Verification #:_____________________________ Date:___________

1. Warning: 18 U.S.C. 1001 provides, among other things, that whoever knowingly and willfullymakes or uses a document or writing containing any false, fictitious, or fraudulent statement orentry, in any manner within the jurisdiction of any department of agency of the United States,shall be fined not more than $10,000 or imprisoned for not more than five years, or both.

The following footnotes pertain to noncitizens who declare eligible immigration status in one of thefollowing categories.

2. Eligible immigration status and 62 years of age or older. For noncitizens who are 62 yearsof age or older or who will be 62 years of age or older and receiving assistance under a section214 covered program on June 19, 1995. If you are eligible and elect to select this category youmust include a document providing evidence of proof of age. No further documentation ofeligible immigration status is required.

3. Immigrant status under §101(a)(15) or 101(a)(20) of INA. A noncitizen lawfully admitted forpermanent residence, as defined by §101(a)(20) of the Immigration and Nationality Act (INA), asan 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 or210A of the INA (8 U.S.C. 1160 or 1161), [special agricultural worker status], who has beengranted lawful temporary resident status.

4. Permanent residence under §249 of INA. A noncitizen who entered the U.S. before January1, 1972, or such later date as enacted by law, and has continuously maintained residence in theU.S. since then, and who is not ineligible for citizenship, but who is deemed to be lawfullyadmitted for permanent residence as a result of an exercise of discretion by the AttorneyGeneral under §249 of the INA (8 U.S.C. 1259) [Amnesty granted under INA 249].

5. Refugee, asylum, or conditional entry status under §§207, 208 or 203 in INA. A noncitizenwho is lawfully present in the U.S. pursuant to an admission under §207 of the INA (8 U.S.C.1157) [refugee status]; pursuant tot he 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 conditionalentry under §203(a)(7) of the INA (U.S.C. 1153(a)(7) before April 1, 1980, because ofpersecution or fear of persecution on account of race, religion, or political opinion or because ofbeing uprooted by catastrophic national calamity [conditional entry status].

6. Parole Status under §212(d)(5) of INA. A noncitizen who is lawfully present in the U.S. as aresult of an exercise of discretion by the Attorney General for emergent reasons or reasonsdeemed strictly in the public interest under §212(d)(5) of the INA (8 U.S.C. 1182(d)(5) [parolestatus].

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

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

Instructions to Housing Authority: Following verification of status claimed by persons declaring eligibleimmigration status (other than for noncitizens age 62 or older and receiving assistance on June 19, 1995), HAmust enter INS/SAVE Verification Number and date that it was obtained. A HA signature is not required.

Instructions to Family Member for Completing Form: On opposite page, print or type first name, middleinitial(s), and last name. Place an “X” or “�” in the appropriate boxes. Sign and date at bottom of page. Place an“X” or “�” in the box below the signature if the signature is by the adult residing in the unit who is responsiblefor Child.

PARENT/ GUARDIAN RESPONSIBILITY FORM

I, _______________________________________, will be responsible for any bills, including Parent/Guardian utilities, gas, or maintenance charges, incurred by ____________________________________. Applicant/ Resident ___________________________________ _________ Print: Parent/ Guardian name Date ___________________________________ Sign: Parent/ Guardian Address: _____________________________________________ _____________________________________________ Phone: ___________________ (home) ___________________(work) Source of income: ________________________________________ Amount: ________________________________________ Per month/year: ________________________________________

Notary

Regular Contributions Verification MHFA 1/10

VERIFICATION OF REGULAR CONTRIBUTIONS TO: RE:

Name

Social Security Number FROM:

Thank you for your prompt response. All information is confidential. Please contact at ( ) if you have any questions.

PERMISSION FOR RELEASE OF INFORMATION You do not have to sign this form if either the requesting organization or the organization supplying the information is left blank. Release: I hereby authorize the release of the requested information. Information obtained under this consent is limited to information that is no older than 12 months. There are circumstances which would require the owner to verify information that is up to 5 years old, which would be authorized by me on a separate consent, attached to a copy of this consent.

Signature Date

THIS SECTION TO BE COMPLETED BY PERSON PROVIDING REGULAR CONTRIBUTIONS

*I hereby certify that I contribute $__________________ per Week / Month / Year to the support of: Name Address City State Zip Code * Include amounts paid directly to the person for whom you are providing support as well as bills and other living expenses regularly paid on the person’s behalf such as utilities, phone, car payment, insurance, cable TV, etc. Notes/additional information:

Signature: Date: Print your name: Tel. #: Title/Relationship: Address PENALTIES FOR MISUSING THIS CONTENT: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposes cited above. Any person who knowingly or willingly requests, obtains, or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages and seek other relief, as may be appropriate, against the officer or employee of HUD or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security act at 208 (a) (6), (7) and (8). Violations of these provisions are cited as violations of 42 USC 408 (a), (6), (7) and (8).

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