the processing of all applications for housing include ... application 2.pdfcha may be ticketed. xi....

The Processing of ALLApplications for Housing Include:

-Police Backgrounds-Credit Checks

-Landlord Checks

Bad reports on any of the aboveitems WILL result in cancellation

of your application!

Any fraud or untruthful statementon any part of your application forhousing will cause IMMEDIATE

cancellation of your application!

Applying for Public Housing

1st Step - Complete the application document (see instructions below).

General Information• The online application is a fillable PDF document, which requires the Adobe Acrobat program. Your computer shouldalready have Adobe Acrobat on it. However, if your computer does not have this program, it is readily available onlinefor free. All of your information (except signatures) can be typed into the application document while online. Thecompleted application document can then be printed out on 8.5 in. x 11 in. white paper. This function has been providedin an effort to save you time and money by eliminating a trip to our office to pick up the application package andpreventing errors that might cause the application to be considered incomplete.• If you prefer, you may print a blank online application or pick up an application package at our office and complete itby hand (in ink only).• The application should be truthfully and thoroughly completed. Untruthful or misleading statements on the applicationis considered fraud and will result in derogatory action up to and including application cancellation, eviction, and/orcriminal prosecution.• N/A should be written in those portions of the application that are Not Applicable to you or your household.

Page 1I. Applicant Information - This portion of the document is where the individual completing the application shouldreflect their name and contact information. This information is vital when we need to contact you regarding the status ofyour application. You should ensure that this information always remains accurate and immediately update it with ouroffice if any changes occur.

II. Household Composition - The member of your household that will be the primary contact point for the familyshould be listed in position number 1, which is designated Head of Household. The other members of the householdshould be listed in the remaining positions (2 - 8), as applicable. ALL PERSONS THAT WILL BE LIVING ORSTAYING IN YOUR HOUSEHOLD MUST BE LISTED. PURPOSEFULLY OMITTING PERSONS THAT WILLLIVE OR STAY IN YOUR HOUSEHOLD IS CONSIDERED FRAUD AND WILL RESULT IN DEROGATORYACTION UP TO AND INCLUDING APPLICATION CANCELLATION, EVICTION, AND/OR CRIMINALPROSECUTION.

Page2 II. Household Composition (Continued) - Additional space to list household members if needed.

III. Absent Parent Information - List the parent(s) of any child in your household that will not reside in yourhousehold with you and the child. Applications without this information will be considered incomplete and Refusal toprovide this information will result in application cancellation. Example: Jane Doe and John Doe are divorced and haveseparate households. Jane Doe and John Doe have a juvenile son Jimmy. Jane Doe has custody of Jimmy at least 51% ofthe time and has submitted an application for housing listing Jimmy in position 2 on the Household Composition portionof the application. Therefore, John Doe’s information must be listed in the Absent Parent portion of the application.The number of the position the child is listed in the Family Composition portion of the application should be reflected inthe FAMILY MEMBER NUMBER column (see below).

FAMILYMEMBERNUMBER(See Pg. 1or Above)

ABSENT FATHER’S/MOTHER’S NAME ABSENT PARENT’S ADDRESS (Street or P.O. Box, City, State & Zip)

COMMENTS

2 John Doe 1234 Main Street, Timbuktu, AL. 55667 None

IV. Income Information - This information in this section must be complete and accurate to ensure eligibility. Answer

the questions in this portion of the application by marking the appropriate boxes and filling in the blanks. List ALLemployment income - Complete this portion of the application for any household members that works a wage paying job,including self-employment. Example: Bob Smith and Sara Smith have submitted an application for housing. Bob is theHead of Household and is listed in position 1 and Sara is listed in position 2 on the Household Composition portion ofthe application. Bob works for XYZ Construction Company and Sara works for S&S Cash and Carry. The number of theposition the wage earning household member is listed in the Family Composition portion of the application should bereflected in the FAMILY MEMBER NUMBER column (see below).


NAME, ADDRESS & PHONE NUMBER OF EMPLOYEROCCUPATION

YEARSEMPLOYED

HOURLY PAY

RATE

PAY PERIOD(Ex. Weekly, Bi- weekly, Etc.)

HOURSWORKEDPER PAY PERIOD

1 XYZ Construction Co., P.O. Box 1, Mobile, AL. 36666 555-5656 Carpenter 3 $10.00 Bi-weekly 80

2 S&S Cash & Carry, Mobile, AL. 555-2323 Cashier 1 $7.25 Weekly 25

List ALL other sources of income - Complete this portion of the application for any household member that receivesnon-wage income, including any income that you are entitled to but may not be receiving. Example: Bob and Sara Smithhave submitted an application for housing. Bob and Sara have a son together named David. David is handicapped andreceives Social Security Income (SSI). Sara also has a daughter named Anna from a previous marriage, who shereceives court ordered child support for. David is listed in position 3 and Anna is listed in position 4 on the HouseholdComposition portion of the application. The number of the position the household member is listed in the FamilyComposition portion of the application should be reflected in the FAMILY MEMBER NUMBER column (see below).

FAMILY MEMBER NUMBER (See Pg. 1 or Above)

SOURCE OF INCOME AMOUNT OF INCOME FREQUENCY RECEIVED (Ex. Weekly, Bi-weekly, Monthly, Etc.)

3 Social Security Income $595.00 Monthly

4 Child Support $100.00 Monthly

Military Information - Answer the questions in this portion of the application by marking the appropriate box. Completethis portion of the application for any household member that is serving active or reserve duty.

Bank Information - Complete this portion of the application for any household member that has any account(s) with abank or credit union. Answer the questions concerning investments (stocks, bonds, real-estate, insurance, etc.) bymarking the appropriate box.

V. Expenses - The information in this section must be complete and accurate to ensure that you are receiving all eligibledeductions. Answer the questions in the Childcare and Special Needs portions of the application by marking theappropriate boxes and filling in the blanks.

Page 4V. Expenses (continued) - The information in this section must be complete and accurate to ensure that you are receivingall eligible deductions. Answer the questions in the Medical and Utilities portions of the application by marking theappropriate boxes and filling in the blanks.

VI. Rental History - The information in this section will be used to screen housing applicants and must be complete andaccurate to ensure eligibility. Information in this section will be cross referenced with the Equifax credit report to ensurefull and complete disclosure of prior rental history. If you have never rented/leased an apartment or home in the past,check the box at the top for Not Applicable (N/A). If you are currently renting/leasing, complete part 1. If you haverented/leased in the past but are not currently renting/leasing, then complete part 2 and part 3 - if more than one pastLandlord. If you are currently renting/leasing and have rented/leased multiple times in the past, complete parts 1, 2 and3. Complete this portion of the application by marking the appropriate boxes and filling in the blanks.

VII. Marital Status History - Complete this portion of the application by marking the appropriate boxes and filling inthe blanks.

VIII. Additional Information - Complete this portion of the application by marking the appropriate boxes and filling inthe blanks.

IX. Program Information - Complete this portion of the application by marking the appropriate boxes and filling in theblanks. The information in this section will be used to screen housing applicants and must be complete and accurate toensure eligibility. The questions in this section concern CRIMINAL RECORDS. If you or a household member haveever been CONVICTED OF A CRIME regardless of the type of offense - you must answer in the affirmative. Giveexplanation(s) regarding criminal record in the space provided by part 2 of this section. PURPOSEFULLY OMITTINGINFORMATION REGARDING CRIMINAL INFORMATION IS CONSIDERED FRAUD AND WILL RESULT INDEROGATORY ACTION UP TO AND INCLUDING APPLICATION CANCELLATION, EVICTION, AND/ORCRIMINAL PROSECUTION.

Page 6X. Applicant/Tenant Vehicle Information - Complete this portion of the application by marking the appropriate boxesand filling in the blanks. If you intend to park a motorized vehicle on the streets within the Housing Authority, thissection must be completed. Vehicles that do not have a CHA issued permit that are found parked on streets within theCHA may be ticketed.

XI. Other Information - Complete this portion of the application by filling in the blanks. This family informationshould be a local and reliable alternate contact point that can be notified if we are having difficulty getting in touch withyou.

Signatures - Leave the signature blanks unsigned. The application must be signed in the presence of a HousingAuthority staff member at the time the application is submitted to our office.

2nd Step - Submit your application at our office and complete the supplementary documents (seeinstructions below).

• Applications are accepted in our office located at 604 Dumont Street, Chickasaw, Alabama on Wednesday’s only fromthe hours of 8:00 A.M. - 11:00 A.M. and 1:00 P.M. - 4:00 P.M.• Applications are not accepted on any Wednesday that lands on the last working day of the month or the 3rd calendar dayof the month.• To apply for an apartment you must be a legally married couple, one of whom is at least 18 years of age (marriage licenserequired) or an individual at least 19 years of age.• You need to bring the following documents with you:

-Valid Driver’s License or State Issued ID Card (MUST Have for all adults) originals only-Social Security Card (MUST Have for Everyone in household) originals only-Birth Certificate (MUST Have for everyone in household) originals only-Marriage license/Divorce Decree/Death Certificate (if applicable)-If you are on SS or SSI you need to bring your award letter-If you are on TANF we need a copy of your award letter

• You MUST have a VALID Driver’s License or State ID Card and original/legible Social Security Cards (forEVERYONE that will be on the application) when the application is returned. Applications WILL NOT be processedwithout these documents.• The processing of an application includes, but is not limited to: Prior landlord verifications, police backgroundcheck and a credit check, on all adults age 18 and up. Your application can be cancelled if negative reports arereceived on any of these items.• Return all forms included with your application to the Chickasaw Housing Authority Office.• Application CANNOT be faxed, mailed, brought in by someone else, etc. ; it must be returned in person.• It will take approximately 30 - 45 minutes to complete the application process in our office so plan accordingly.

Chickasaw Housing Authority APPLICATION Telephone Number: (251)457-6841 Fax Number: (251)457-9751

Housing Authority Use ONLY

�Everything below this Line is to be completed by Applicant (print in ink)� Answer N/A for items that do no apply to you. Do not leave anything blank!

I. Applicant Information -

II. Household Composition - List ALL persons that will live in the rental unit while you are on the Public Housing program.

No. PRINT FULL NAME RELATIONTO HEAD

SEX (M or F)

DATE OF BIRTH

AGE PLACE OF BIRTH U.S.CITIZEN(Y or N)

SOCIAL SECURITY NUMBER

1. HEAD

2.

3.

II. Household Composition (Continued on Next Page)

Application #: Application for Admission G

Date: Time: A.M. - G P.M. - G

Application for Continued Occupancy

Re-exam Date: Current: Previous:

Deposits Regular Deposit: Pet Deposit:

Other Deposit: Total Deposit:

Family StatusNo. in Family: Sex of Head: F - G M - G

No. of Minors: Head/Spouse 62 or Over: G

No. of Bedrooms: Head/Spouse Disabled: G

Age of Head: Spouse Deceased: G

Husband/Wife Present: G Separated: G

Single: G Divorced: G

OtherLocal Preference: Credit Score:

Eligible: G Ineligible: G

Rent Amount:

Notes:

Racial Group EthnicityWhite: G Hispanic/Latin: G

African American: G Non-Hispanic/Latin: G

Asian orPacific Islander: G

American Indian orAlaskan Native: G

Other: G

Name: First Last M.I.

Physical Address: Street City State Zip

Mailing Address: Street City State Zip

Home Phone #: Work Phone #:

Cell #: Can You Receive Text?: No G Yes G

E-mail Address:____________________________________________

1

msweet

Highlight

No. PRINT FULL NAME RELATIONTO HEAD

SEX (M or F)

DATE OF BIRTH

AGE PLACE OF BIRTH U.S.CITIZEN(Y or N)

SOCIAL SECURITY NUMBER

4.

5.

6.

7.

8.

Are any changes in your family composition anticipated? No G Yes G If Yes, explain:

III. Absent Parent Information - List ALL absent parent(s) for ANY children that will be living in your household. Theapplication will be considered incomplete without this information.


ABSENT FATHER’S/MOTHER’S NAME ABSENT PARENT’S ADDRESS (Street or P.O. Box, City, State & Zip)

COMMENTS

IV. Income Information -Do you have Zero ($0.00) family income? No G Yes G (If Yes, you may be required to complete a Zero Income questionnaire)

Are you or any adult member of your household a full-time (12 Semester hours or more) student? No G Yes G

If Yes, where are you/they enrolled:

List ALL employment income (including self-employment) for each household member:


NAME, ADDRESS & PHONE NUMBER OF EMPLOYER OCCUPATION YEARSEMPLOYED

HOURLY PAY

RATE

PAY PERIOD(Ex. Weekly, Bi- weekly, Etc.)

HOURSWORKEDPER PAY PERIOD

List ALL other sources of income: examples include (but are not limited to) - Welfare/TANF, Social Security, SSI, pensions,survivor benefits, disability compensation, food stamps, unemployment compensation, baby-sitting, daycare subsidy, child support,alimony, annuities, interest, dividends, income from rental property, Armed Forces or Military Reserve, VA Benefits, cash or inkind contributions from individuals, scholarships, or grants. You must include alimony and/or child support that you areentitled to but may not be receiving.

FAMILY MEMBER NUMBER (See Pg. 1 or Above)

SOURCE OF INCOME AMOUNT OF INCOME FREQUENCY RECEIVED (Ex. Weekly, Bi-weekly, Monthly, Etc.)

2

Military Information: is there any member of your household now serving active duty or reserve in the Military Service (Army,

Navy, Air Force, Marines, etc.)? No G Yes G If Yes, give the following information on each military person:

FAMILY MEMBER NUMBER (See Pg. 1 or 2)

RANK BRANCH OF SERVICE

ADDRESS OF MILITARY EMPLOYER

Bank Information: list any/all checking, savings, credit union, certificate of deposit accounts, etc.

FAMILY MEMBER NUMBER

(See Pg. 1 or 2)

TYPE OF ACCOUNT BANK ACCOUNT NUMBER CURRENT BALANCE

Do you own:

1. Stocks & Bonds - No G Yes G If Yes, current value: $

2. Savings Bonds - No G Yes G If Yes, current value: $

3. Real Estate (land or houses) - No G Yes G If Yes, current value: $

Have you EVER owned real estate? - No G Yes G If Yes, when:

4. Life Insurance or Retirement Account(s) - No G Yes G If Yes, current value(s): $

V. Expenses -Childcare:

Special Needs:

1. Do you pay out-of-pocket for childcare expenses to allow a family member to work or go to school? No G Yes G

If Yes, list the childcare provider’s - Name:

Mailing Address:

Telephone Number(s):

2. Childcare/Baby-sitting Cost: G weekly $ OR G monthly $

3. Do you receive assistance for childcare costs (Ex. Childcare South, family contributions, etc.)? No G Yes G

If Yes, who provides your childcare assistance?

Value of childcare assistance: G weekly $ OR G monthly $

1. For determining allowable income deductions, does any member of your household have a disability? No G Yes G

2. Does any member of your household require special accommodations? No G Yes G If Yes, what special

accommodations are needed:

3. Do you pay for a care attendant or for any equipment for any member with a disability in order to permit that person or

someone else in the family to work? No G Yes G If Yes, describe expenses:

3

Medical:

Utilities:

VI. Rental History - Provide the information below for your current and two previous Landlords. Check the box here G toindicate Not Applicable (N/A) if you have never rented/leased before.

1. Are you paying for Medicare benefits? No G Yes G If Yes, monthly amount paid $

2. Are you receiving medical assistance through the welfare department (DHR)? No G Yes G

If Yes, monthly amount of benefits $

3. Do you pay out-of-pocket for any medical insurance/hospitalization (such as BlueCross)? No G Yes G

If Yes, indicate amount per payment: G weekly $ OR G bi-weekly $ OR G monthly $

4. Are you making payments on outstanding medical bills? No G Yes G If Yes, amount paid per month $

5. Do you pay out-of-pocket for any prescription drugs on a regular basis? No G Yes G

If Yes, amount paid per month $

If you pay for your own utilities, check the box beside the utilities listed below that are paid by you and indicate the amount. If

you do not pay for ANY of the utilities listed, check the box here G to indicate Not Applicable (N/A).

1. Electricity: No G Yes G If Yes, monthly amount $ 2. Gas: No G Yes G If Yes, monthly amount $

3. Water: No G Yes G If Yes, monthly amount $ 4. Sewage: No G Yes G If Yes, monthly amount $

5. Garbage: No G Yes G If Yes, monthly amount $ 6. Phone: No G Yes G If Yes, monthly amount $

7. Cell Phone: No G Yes G If Yes, monthly amount $ 8. Cable TV: No G Yes G If Yes, monthly amount $

9. Other - : No G Yes G If Yes, monthly amount $

1. Name of Current Landlord:

Mailing Address of Landlord: Street City State Zip

Monthly Rent $ Number of Bedrooms: Number of Persons in Household:

How long have you been a tenant of this Land lord? Years: Months:

Do you owe any money to the Landlord named above? No G Yes G If Yes, amount owed $

2. Previous Residence Address : Street City State Zip

Name of Previous Landlord:


How long were you a tenant of this Landlord? Years: Months:

3. Previous Residence Address :

Street City State Zip

Name of Previous Landlord:


How long were you a tenant of this Landlord? Years: Months:

4

VII. Marital Status/History -

VIII. Additional Information -

IX. Program Information -

1. Have you ever been married? No G Yes G If Yes, how many times? Maiden Name:

2. Have you ever been separated? No G Yes G

If Yes, from who: Date Name Street Address City State Zip

3. Have you ever been divorced? No G Yes G

If Yes, from who: Date Name Street Address City State Zip

4. Are you widowed? No G Yes G

If Yes, provide Social Security Number(s) of deceased:

5. Any additional comments:

1. Have you ever used a name or Social Security number other than the one you are using now? No G Yes G

If Yes, explain:

2. Have you ever applied for Public Housing or Section 8 Housing? No G Yes G

3. Have you ever lived in Public Housing or Section 8 Housing? No G Yes G

4. Have you ever lived in housing that is referred to as the “PROJECTS”? No G Yes G

5. If you have lived or currently live in Public Housing (Projects) and/or Section 8 Assisted Housing or housing where the

amount of rent you paid was based on your income, complete the following:

Where (address): When (dates):

6. Do you owe any money to a Public Housing Authority, Project or Section 8 Housing Program? No G Yes G

If Yes, how much $

1. Have you or any family member listed on this application ever been CONVICTED of any crime? No G Yes G

2. If you answered Yes to question #1. above, explain in detail:

!!!NOTICE!!! - Your are reminded that criminal records will be verified through local, stateand federal law enforcement crime information data systems. The CHA primarily conducts anation wide criminal background check through the FBI’s National Crime Information Center(NCIC). Giving false information on your application is considered fraud and will result inthe cancellation of your application or eviction if you have been housed. Applicants will berequired to provide supplemental information to document any mitigating circumstances,dispute crime data, or show disposition of any open cases that are listed in NCIC.

5

X. Applicant/Tenant Vehicle Information - Check the box here G to indicate Not Applicable (N/A) if you will not be parking amotorized vehicle (car, truck, van, suv, motorcycle, etc.) on the streets within the Housing Authority. Note: All vehicles parkedon City streets within the CHA are required to obtain and display a parking permit sticker.

XI. Other Information -

WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements ormisrepresentations to any Department or Agency of the Unites States as to any matter within its jurisdiction.

I/We certify that all information given to the Chickasaw Housing Authority in this application is correct. I/We understand andacknowledge that, if these facts are not true, housing assistance or housing will not be provided, and I/We will be declaredineligible. I/We understand that after the information in this application is verified, it will be submitted to the U.S. Department ofHousing and Urban Development (HUD) on Form HUD-50058 (the Federal Privacy Act Statement contains additional informationconcerning the authorized use of this information). I/We also understand that staff of the Chickasaw Housing Authority will verifythis information, and I authorize the Chickasaw Housing Authority to submit inquiries necessary for the purpose of verifying thefacts herein stated.

Signature: Date: Head of House

Signature: Date: Spouse or Other Adult

Signature: Date: Other Adult

CHA Representative:

Note: If you believe that you have been discriminated against, you may report the incident by calling the Fair Housing andEqual Opportunity toll-free hotline at 1(800)669-9777, or by asking the Chickasaw Housing Authority to provide you with aHUD Housing Discrimination Complaint Form (HUD-903).

1. Are you the registered owner of this vehicle? No G Yes G If No, complete the following information:

Name and address of owner: Name Street City State Zip

2. Vehicle Information:

Year/Make/Model: License Plate Number:

Color: Vehicle Identification Number (VIN):

Liability Insurance Provider:

Name of your relative that lives nearest to you: Relationship:

Address of relative: Street City State Zip

Telephone number(s):

6

THE HOUSING AUTHORITY OF THE CITY OF CHICKASAW604 Dumont Street

Chickasaw, AL 36611251-457-6841 Fax 251-457-9751

Date: Tenant:

Landlord: S.S. Number:

Address: Address:

The above named individual has applied for low-income housing. He/she has given your name as a former/presentlandlord reference. We would appreciate it if you would complete the following questionnaire. Please return this formwithin (10) ten days from the date above, if possible, in the enclosed self-addressed, stamped envelope or by fax.

Thank you, I have no objection to your giving the below requested

Shay Cain information and request you to do so. Lease & Occupancy Specialist

Applicant Signature:

1. How long were they in residence? From: To:

2. Who lived in the household?

3. How did they pay their rent? On Time Late

4. Would you rent to Him/Her again? Yes No If not, why?

5. How did He/She keep the premises?

6. Were they considerate of their neighbors? Yes No

7. How did they get along with others?

8. Did the tenant control their children and were they well behaved? Yes No

If no, explain:

9. Did they have loud parties? Yes No

10. Were there any kind of disturbances/incidents that police action had to be taken? Yes No

If yes, explain:

11. Did the tenant damage your property beyond the due-to-normal wear and tear? Yes No

If yes, explain:

12. Did the tenant have housekeeping habits that affected the other tenants’ welfare, health and safety? Yes No

If yes, explain:

13. Was the unit left in good condition? Yes No

If no, explain:

14. Amount of rent paid: $ Balance left owed, if any: $

15. Comments:

Landlord’s Signature: Telephone # Date

CHICKASAW HOUSING AUTHORITY604 DUMONT STREET

CHICKASAW, ALABAMA 36611(251)457-6841

FAX: (251)457-9751

SOURCES OF INCOME

TYPE OF INCOME AMOUNT FREQUENCYTANF ____________ ________________Food Stamps ____________ ________________Child Support ____________ ________________Social Security ____________ ________________Social Security Disability ____________ ________________Supplemental Security ____________ ________________Supplemental Security Disability ____________ ________________Veterans Benefits ____________ ________________Alimony ____________ ________________Child Care South ____________ ________________Family Contributions ____________ ________________Other ____________ ________________

EMPLOYERS’S NAME/ADDRESS

1. ____________________________________________________________________________________________________________________

2. ____________________________________________________________________________________________________________________

OCCUPATION YEARS PAY RATE HRS. PER WEEK______________ _______ __________ ______________________________ _______ __________ ________________

Applicant /Tenant is advised that any person who obtains or attempts to obtain, or who establishes or attempts to establish eligibility forany person who knowingly or intentionally aids or abets such person in obtaining or attempting to obtain housing or a reduction inpublic housing rental charges, or any rent subsidy, to which such person would not otherwise be entitled, by means of a false statement,failure to disclose information, impersonation or other fradulent scheme or devise shall be guilty of a misdemeanor and, uponconviction, shall be punished by fine of not less than $300.00 nor more than $500.00 or be punished at hard labor for the county not toexceed 60 days, or may be both fined and imprisoned, at the discretion of the court. (24-1-10, Code of Alabama, 1975.)

THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE AND I HAVE NOOBJECTION TO INQUIRIES FOR THE PURPOSE OF VERIFYING THE FACTS HEREIN STATED.

_________________________________________________ ______________________SIGNATURE OF APPLICANT/TENANT DATE

THE HOUSING AUTHORITY OF THE CITY OF CHICKASAW

Eligibility Consent Form

Each member of the family of an applicant or participant who is at least 18 years of age, and eachfamily head and spouse regardless of age, shall sign this consent form. Applicants will sign theconsent form when applying for assistance and participants will sign the form at the nextregularly scheduled income reexamination.

I authorize the Department of Housing and Urban Development (HUD) and the ChickasawHousing Authority (CHA) to obtain from the State Wage Information Collection Agencies(SWICAs) any information or materials necessary to complete or verify the application forparticipation or maintain continued assistance under the program administered by the HA.

I also authorize HUD and CHA to verify income information necessary for determiningeligibility or continue assistance for previous employers or current employer.

I also authorize HUD to request income return information from the IRS and the Social SecurityAdministration for the sole purpose of verifying income information pertinent to the applicant’sor participant’s eligibility.

This consent form will expire 15 months after the date the consent form is signed.

______________________________________________________________________________Print Full Name (Head of Household) Signature Date

______________________________________________________________________________Print Full Name (Spouse) Signature Date

______________________________________________________________________________Print Full Name (Household Member Signature Date18 years of age of older)



Failure to sign this consent form will result in denial of assistance and/or termination ofassistance.

THE HOUSING AUTHORITY OF THE CITY OF CHICKASAW

PUBLIC HOUSING, SECTION 8 CERTIFICATES AND VOUCHERS PROGRAMS

DECLARATION OF UNITED STATES CITIZENSHIP

I hereby declare, under penalty of perjury, that I am a citizen of the United States of America.

Print Name: Signature: Head of Household Date

Print Name: Signature: Spouse Date

Print Name: Signature: Household Member Date





Witness: Signature Date

Note: For each adult, the form must be signed by the adult. For each child, the form must be signed by an adultmember of the family residing in the assisted dwelling unit who is responsible for the child.

This document will be filed in the head-of-household’s file folder and serve as verification and evidence ofdeclaration of U. S. Citizenship.


Chickasaw, AL 36611251-457-6841 (Fax) 251-457-9751

AUTHORIZAnON

Name _

Address _

Social Security Number _

Telephone Number _

The following named agencies are authorized to give the Chickasaw Housing Authority information to

determine eligibility for admission to and/or continued occupancy oflow-rent public housing units operated

by the Chickasaw Housing Authority and to determine rent for these units:

- Social Security Administration

- Department of Pensions & Security

- Department of Veterans Affairs

- Food Stamp Office

- Internal Revenue Service

- Mobile County Board of Health

- Mobile Mental Health Center

- Chickasaw Police Department

- Banks and other Financial Institutions

- Courts

- Law Enforcement Agencies

- Credit Bureaus

- Employers, Past and Present

- Landlords

- Providers of:AlimonyChild CareChild SupportCreditHandicapped Assistance.Medical CarePensions/Annuities

- Schools and Colleges

- Utility Companies

- Unemployment Verification

- Welfare AgenciesSignature: HEAD Date _

Signature: SPOUSE Date _

Signature: OTHER Date _

Witness: (If signed by "X" mark) _

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

gcgoodwin

Typewritten Text

CHICKASAW HOUSING AUTHORITY 604 DUMONT STREET CHICKASAW, ALABAMA 36611 EQUAL HOUSING OPPORTUNITY

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.

Chickasaw Housing Authority Accommodation Request Verification

Date: To:

Health Care Provider’s Name

Address: Health Care Provider’s Address

Definition of Disabled: Under Federal law, an individual is disabled if he/she has a physical or mental impairment that substantially limits one or more major life activities; has a record of such impairment; or is regarded as having such impairment. The term "physical or mental impairment" includes, but is not limited to, such diseases and conditions as orthopedic, visual, speech, and hearing impairment, cerebral palsy, autism, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes, Human Immunodeficiency Virus infection, mental retardation, emotional illness, drug addiction, and alcoholism. This definition doesn't include any individual who is a drug addict and who is currently using illegal drugs or an alcoholic who poses a direct threat to property or safety because of alcohol use. Live-In Aide: A person who resides with an elderly person(s), near elderly person(s) or person(s) with disabilities and who: (a) is determined by HA to be essential to the care and well being of the person(s); (b) is not obligated to support the family member; and (c) would not be living in the unit except to provide the necessary supportive services [24 CFR 5.403]. Occasional, intermittent, multiple or rotating care givers do not meet the definition of a live–in aide since live-in-aides must reside with a family permanently for the family unit size to be adjusted in accordance with the subsidy standards established by the PHA.

Health Care Provider’s Certification: My signature below certifies that I have read and fully understand the definitions of “disabled,” “Live-In Aide,” and the penalty for misusing this form.

Health Care Providers Signature Date

Note Both page 1 and 2 MUST be completed and returned to receive consideration

Penalties For Misusing This Verification Form: Title 18, Section 1001 of the U. S. Code states that a person is guilty of a felony for knowingly and willingly making false statements to any department of the United States Government, including the Department of Housing and Urban Development (HUD) or a Public Housing Authority. HUD, the Housing Authority and any employee of HUD or the Housing Authority 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 willfully requests, obtains or discloses any information under false pretenses concerning an applicant or resident may be subject to a misdemeanor and fined not more than $5,000. Any applicant or resident 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 Housing Authority for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Act at 42 U.S.C. 208 (f)(g) and (h). Violation of these provisions are cited as violations of 42 U.S.C. 408 f, g, and h.

Applicant/Resident Information: Applicant/Resident Name:

Address:

Accommodation Requested By Resident/Applicant

The person named above has applied for or is receiving federal rental assistance. The person has requested an accommodation based on a disability or medical need. If a person who is elderly (age 62 or older), near elderly (age 52 to 61), or has a disability requests an accommodation, the Housing Authority must consider the request. The Housing Authority must determine whether the person qualifies as disabled under federal law and/or whether the person requires an accommodation in order to have an equal opportunity to use and enjoy the housing site.

We would appreciate your cooperation in answering the questions on this form and returning it to the Housing Authority. Enclosed is a self-addressed envelope for this purpose. The person listed above has consented to the release of this information, as shown below.

Authorization to Release Information: 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. Where there are circumstances which would require the Housing Authority to verify information that is up to five years old, a separate consent attached to a copy of this consent was provided/authorized by me on:

Applicant/Resident Signature Date

Information Requested:

1. Is the person listed above disabled, as defined on page 1? Yes No

2. In your professional opinion, and by definition, does the person listed above require the accommodation requested? Yes No

3. Please provide (in the space below) any medical information that would be helpful to the Housing Authority in making a decision.

Name of Physician Supplying Information Title

Name of Organization/Practice/Hospital

Signature of Physician Supplying Information Date

Note

Both page 1 and 2 MUST be completed and returned to receive consideration


Chickasaw, AL 36611251-457-6841

APPLICANTIRESIDENT CERTIFICATION

Applicant(s)/Resident(s) Statement

I/we certify that the information* given to the Chickasaw Housing Authority on householdcomposition, income, net family assets, and allowances and deductions is accurate andcomplete to the best ofmy/our knowledge and belief. I/we understand that false statementsor infonnation is punishable under Federal Law. I/we also understand that false statementsor information is grounds for termination ofhousing assistance and termination ofresidency.

Signature ot Head ot Household

Signature of Spouse

bate

Date

If you believe you have been discriminated against, you may call the Fair Housing and EqualOpportunity National Toll-Free Hot Line at 800-424-8590. (Within the Washington D.C.Metropolitan Area, call 426-3500.)

*After verification by this Housing Authority, the information will be submitted to theDepartment of Housing and Urban Development on Form HUD - 50058 (Tenant DataSummary), a computer-generated facsimile ofthe form or on magnetic tape. See the FederalPrivacy Act Statement for more information about its use.

LOCAL PREFERENCES

No. Local Preferences (Definitions listed below table) Points Total Points

1 Minimum income of $10,000/year with at least 6 months jobhistory

600

2 Working family 400

3 Current Chickasaw resident or work within the City limits 300

4 Veteran 200

5 Elderly family over single person (1 BR only) 2

6 Near elderly family over single person (1 BR in units designatedfor elderly only)

0

Total:

Read and sign warning before completing this application!

WARNING

***********************NOTICE********************ONCE YOU HAVE SUBMITTED YOUR APPLICATION TO THE

CHICKASAW HOUSING AUTHORITY IT BECOMES THEPROPERTY OF THE HOUSING AUTHORITY.

****************************************************Misrepresentation is a serious dwelling lease violation that may result in eviction. If it is found that an applicant or tenant has misrepresented the facts upon which his/her rent is based so that he/she is paying less than he/she should be paying, the dwelling lease and/or housing assistance will be terminated. In addition, the applicant/tenant may be subject to civil and criminal penalties. Alabama law in part defines Public Assistance Fraud and the penalties as follows – Public assistance means money or property provided directly or indirectly to eligible persons through programs of the federal government, the state, or any political subdivision thereof, including any program administered by a public housing authority. It shall be unlawful for an individual or business entity to knowingly do any of the following: (1) Fail, by false statement, misrepresentation, impersonation, or other fraudulent means, to disclose a material fact used in making a determination as to the qualification of the person to receive public assistance. (2) Fail to disclose a change in circumstances in order to obtain or continue to receive any public assistance to which he or she is not entitled or in an amount larger than that to which he or she is entitled. (3) Aid and abet another person in the commission of the prohibitions enumerated in subdivision (1) and (2) or in any way receive, attempt to receive, or aid and abet in the receipt of unauthorized payments orother unauthorized payments or other unauthorized public assistance or authorization or identification toobtain public assistance. In addition to any other penalty provided by law, an individual or business entity thatviolates this section in an aggregate value of two hundred dollars ($200) or more shall be guilty of a Class Cfelony. OR an individual or business entity that violates this section in an amount less than the aggregate value oftwo hundred dollars ($200) shall be guilty of a Class A misdemeanor. Three (3) or more violations of this sectionshall establish a rebuttable presumption that the individual knowingly violated this section (13A-9-150, Code ofAlabama, 1975).

Signature:________________________________________ Date:___________________

Documents that you MUST have with you to submit an application:

1. Social Security Cards for ALL household members.2. Drivers License or Picture I.D. for ALL adult household members.

Other Documents to bring with you: 1. Birth Certificates for ALL household members.2. All FINAL Divorce Decrees/Legal Separation Papers.3. Marriage Certificate/Death Certificate.4. Landlord’s name and complete mailing address for the past 5 years.5. Employer’s name and complete mailing address.6. Most recent Social Security/SSI Award Letter.7. Child Support Court Order or Address of person giving the support.8. Unemployment Letter9. Veterans Benefit Award Letter.10. TANF Award Letter.11. Food Stamp Award Letter.12. Childcare South Award Letter.13. Childcare providers mailing address.

THE HOUSING AUTHORITYOF THE CITY OF CHICKASAW

604 DUMONT STREETCHICKASAW, ALABAMA 36611

(251) 457-6841FAX (251) 457-9751

Dear Housing Applicant:

Your application for housing will now begin the approval process. It will take approximately 2-3 weeks toprocess your application if we have all of your information. If additional information is requested, it needs tobe delivered to Chickasaw Housing Authority immediately. Your housing application will not be consideredcomplete until we have all requested information.

When we have obtained all necessary information, one of the following things will happen:

1. Your application will be approved and you will be placed on the eligible waiting list. You will be called whenan apartment becomes available (DO NOT CALL THE OFFICE REPEATEDLY), or;

2. Your application will be canceled. You will be sent a letter to the address on your application stating thereason for the cancellation. Some of the reasons for cancellation are bad credit, bad landlord report, fraud,police record, etc... It will state on the letter if there is another step you may take to try and receive housing, or;

3. Additional information will be requested in order to complete your application.

Once an application is completed/approved, it moves to the eligible waiting list for the bedroom-size apartmentthat you qualify for. You will be called when your application comes up for housing.

When you are called for an apartment, you will need to have the following:

-At least $100 of your $400 security deposit.-Your 1st months pro-rated rent (which will be determined by the date you actually move in). -You 1st months garbage fee ($20) & filter fee ($2-if you unit has HVAC)-This has to be paid by a personal check, money order or debit/credit card. Cash is NOT accepted.

-You will have to call Spire Energy at 1-800-292-4008 (before you rent) to have gas service put in yourname for the apartment that is going to be rented by you, effective on the day that you are renting. There isnormally a $50 deposit (although the amount varies) that has to be paid to them at that time. You will have toprovide you Spire Energy account number.

-You will have to go to Alabama Power (before you rent) to have power service put in your name forthe apartment that you are renting. You will have to provide a receipt, letter, or work order from AlabamaPower showing the service has been established in your name.

Water for you apartment is included in your rent and all apartments are equipped with gas stoves as well as arefrigerator. Most apartments have a washer and dryer connection but there are a few that do no have either.If you require either of these, you should inform the person taking your application of your needs. Mostapartments within Chickasaw Housing have central heat/air. However, some apartments have a wall heater andno cooling. So, you may need a window a/c unit if you wish to have cold air.

Please do not call the rental office to check the status of your application more that once a week. We callapproved applicants as their name comes up. When we call, you will need to be ready to rent within at least aday or two. We cannot hold apartments for days or weeks while a prospective tenant tries to save up their moneyto move in. YOU WILL RECEIVE ONLY ONE OFFER. You will need to plan ahead for this.