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If you need to request a Reasonable Accommodation in filling out an application please call our office at 782-8585
Date: * YOU MUST FILL OUT THE ENTIRE APPLICATION –
REQUIRED FIELDS (*) MUST BE FILLED OUT OR YOUR APPLICATION WILL NOT BE ACCEPTED
HEAD OF HOUSEHOLD
First Name: * Last Name: * Middle Initial: *
Email: * Phone: *
Address: * City: *
State * Zip: *
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A. FAMILY COMPOSITION – FAMILY MEMBER 1 MUST BE THE NAME LISTED ABOVE THAT IS THE HEAD OF THE HOUSEHOLD.
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List all persons who will be living in your home AND EACH HOUSEHOLD MEMBERS SOCIAL SECURITY NUMBER AND BIRTHDATE
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Family Member 1. ——HEAD OF HOUSEHOLD—————————————
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* Race -1 White – 2 Black – 3 American Indian or Alaskan – 4 Asian or Pacific ** Ethnicity – 1 Hispanic – 2 Non-Hispanic
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First Name * HEAD OF HOUSEHOLD
Last Name *
Middle Initial *
Birthdate *
Social Security # *
Relationship – SELF
Age *
Sex *
Birthplace: City & State *
Race*
Ethnic**
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Family Member 2. ———————————————————————————————————————————–
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First Name *
Last Name *
Middle Initial
Birthdate *
Social Security # *
Relationship *
Age *
Sex *
Birthplace: City & State *
Race*
Ethnic**
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Family Member 3. ——————————————————————————————————
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First Name *
Last Name *
Middle Initial
Birthdate *
Social Security # *
Relationship *
Age *
Sex *
Birthplace: City & State *
Race*
Ethnic**
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Family Member 4. ———————————————————————————————————————————–
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First Name *
Last Name *
Middle Initial
Birthdate *
Social Security # *
Relationship *
Age *
Sex *
Birthplace: City & State *
Race*
Ethnic**
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Family Member 5. ———————————————————————————————————————————–
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First Name *
Last Name *
Middle Initial
Birthdate *
Social Security # *
Relationship *
Age *
Sex *
Birthplace: City & State *
Race*
Ethnic**
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Family Member 6. ———————————————————————————————————————————–
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First Name *
Last Name *
Middle Initial
Birthdate *
Social Security # *
Relationship *
Age *
Sex *
Birthplace: City & State *
Race*
Ethnic**
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Family Member 7. ———————————————————————————————————————————–
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First Name *
Last Name *
Middle Initial
Birthdate *
Social Security # *
Relationship *
Age *
Sex *
Birthplace: City & State *
Race*
Ethnic**
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Anticipated Changes in Family Composition:
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B. SOURCES AND AMOUNTS OF INCOME (Including Asset Income)
List all money earned or received by everyone living in your household. This includes money from wages, self-employment, child support, contributions, Social Security, disability payments (SSI), Workman’s Compensation, retirement benefits, FIP, Veterans benefits, rental property income, stock dividends, income from bank accounts, alimony, and other sources.
Family Member 1. ———————————————————————————————————————————–
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Family Member *
Employer
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Employer Address and Phone # *
Gross Weekly Wages *
FIP *
Child Support *
Gross Social Security *
Unemployment *
All other income *
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Family Member 2. ———————————————————————————————————————————–
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Family Member *
Employer
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Employer Address and Phone # *
Gross Weekly Wages *
FIP
Child Support *
Gross Social Security *
Unemployment *
All other income *
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Family Member 3. ———————————————————————————————————————————–
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Family Member *
Employer
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Employer Address and Phone # *
Gross Weekly Wages *
FIP *
Child Support *
Gross Social Security *
Unemployment *
All other income
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Family Member 4. ———————————————————————————————————————————–
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Family Member *
Employer
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Employer Address and Phone # *
Gross Weekly Wages *
FIP *
Child Support *
Gross Social Security *
Unemployment *
All other income *
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C. ASSETS:
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1 *. Do you or any household member own or have financial interest in any real estate? Yes No
2 *. Have you or any family member disposed of any real estate or assets within the last 2 years? Yes No
3 *. Do you or any family member own any stocks, bonds, or other investments? Yes No
4. *Do you have a checking or savings account, C.D.’s? Yes No
For any yes answers provide description, name and address that pertain.
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D. DEDUCTIONS AND ALLOWANCES. List all medical expenses not covered by insurance that are paid from your monthly income.
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1. Elderly Medical: ………………………………………………………………………………………
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Family Member 1. ———————————————————————————————————————————–
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Family Member
Doctor/Pharmacy/Hospital/Clinic/Insurance
address and Phone Number
Cost
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Family Member 2. ———————————————————————————————————————————–
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Family Member
Doctor/Pharmacy/Hospital/Clinic/Insurance
address and Phone Number
Cost
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Family Member 3. ———————————————————————————————————————————–
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Family Member
Doctor/Pharmacy/Hospital/Clinic/Insurance
address and Phone Number
Cost
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Family Member 4. ———————————————————————————————————————————–
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Family Member
Doctor/Pharmacy/Hospital/Clinic/Insurance
address and Phone Number
Cost
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2. Child Care: …………………………………………………………………………………………………
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Family Member 1. ———————————————————————————————————————————–
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Family Member
Provider’s Name
Provider’s Phone Number and Address
Cost
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Family Member 2. ———————————————————————————————————————————–
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Family Member
Provider’s Name
Provider’s Phone Number and Address
Cost
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F. OTHER INFORMATION:
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1. *Does anyone outside of your household pay any of your bills or give you money? Yes No
Explain if yes
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2 *. Have you or any other adult member ever used any other names(s) or Social Sec. #’s other than the ones you are currently using? Yes No
Explain if yes
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3. *Have you or any household member lived in any assisted housing? Yes No
If yes list where and when
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4 *. Have you or any household member ever been convicted of crimes other than traffic violations? Yes No
Crimes convicted of:
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5. *Have you or any household member ever committed fraud in a Federal assistance housing program or been required to repay money for misrepresenting information for such programs? Yes No
Explain if yes
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6 *. Are you or any member of your household on the lifetime sex offender registration program of any state? Yes No
Explain if yes
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7. *Have you or any member of your household been evicted from any federally assisted program due to drug, alcohol, or any other criminal activities? Yes No
Explain if yes
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G. WAITING LIST PREFERENCES
SIRHA has adopted Waiting List Preferences and gives a preference for Residency, Disabled or Handicapped and Veterans..
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IIT IS YOUR RESPONSIBILITY TO SUBMIT THE REQUIRED DOCUMENTS WITH THIS APPLICATION. If you fail to provide the required documentation with this application you will not qualify for or receive the preference(s).
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Waiting List Preferences
SIRHA has adopted the following Waiting List Preferences
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You may qualify for all the preferences listed below. The more preferences you qualify for the higher you will be placed on the Waiting List and the sooner you will receive rent assistance.
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• Residency Preference
• Category 1 – Any applicant that resides in our 13 County Area (Adair, Adams, Cass, Clarke, Decatur, Fremont, Mills, Montgomery, Page, Pottawattamie, Ringgold, Taylor, or Union County) in Iowa or in Nebraska City, Nebraska at the time of pre-application processing.
• Category 2 – Any applicant that resides in the State of Iowa, but not in our 13 County Area or Nebraska City, Nebraska at the time of pre-application processing.
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• Disabled Preference
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• Veteran Preference
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Qualifying for Waiting List Preferences *
To qualify for and receive a preference it is your responsibility to select the preference on the application and submit the required documentation as listed below. If you fail to submit the required documentation with this application, you will not qualify for or receive the preference.
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• MUST PROVIDE ONE OF THE FOLLOWING:
• Residency Preference – to qualify for this preference you must submit one of the following items with your name and current address on the document:
• Current lease agreement
• Current bill
• Current award letter/letter issued by a government agency
• Government issued ID or Driver’s license
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• Disabled Preference – to quality for the preference you must submit the documentation as stated below:
• Copy of your Social Security or SSI income,
• Disabled/Handicapped – If you are not receiving Social Security or SSI Income, then you must submit a Doctor’s statement verifying your disability.
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• Veteran Preference- to qualify for this preference you must submit one of the following
• Military ID (that shows you are or have served in the military)
• DD 214 Discharge Form
• The family claiming and verification of income from the military or VA for a current veteran family member.
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If you qualify for one or more of the preferences LISTED ABOVE please check below the preference(s) that you can provide documentation for. You need to submit this to us by email to – vchristensen@sirha-ia.org, fax to 641-782-5900 or send by mail.
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RESIDENCY DISABLED VETERAN
I do hereby swear and attest that all of the information above about me is true and correct. I also understand that all changes in the income of any member of the household as well as any changes in the household members must be reported to the Housing Authority in WRITING IMMEDIATELY.
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SECTION 8 AND PUBLIC HOUSING WAITING LISTS
(YOU CAN APPLY FOR BOTH WAITING LISTS ON THIS APPLICATION)
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SECTION 8 PROGRAM
You find a rental unit on the private market and the unit must pass Housing Quality Standard Inspections.
You pay at least 30% of adjusted annual income for rent and utilities.
You are not allowed to pay more than 40% of your adjusted monthly income for rent during the first year of the lease.
You pay your portion of the rent to the private landlord. SIRHA pays the remainder to the landlord.
In some cases the landlord will include utility costs in the rent.
If you pay utilities, a Utility Allowance is subtracted from amount you will pay for rent.
The rental unit will be inspected annually by SIRHA.
Landlords are required to follow State and Federal laws and may collect a security deposit.
Participants CAN NOT rent a unit from an owner (including a principal or other interested party) who is the parent, child, grandparent, grandchild, sister or brother of any member of the family, unless the HA has determined that approving rental of the unit, notwithstanding such relationship, would provide reasonable accommodation for a family member who is a person with disabilities.
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SIRHA serves the following counties on the Section 8 Program: Adams, Adair, Cass, Clarke, Decatur, Fremont, Mills, Montgomery, Page, Pottawattamie, Ringgold, Taylor, and Union in Iowa and Nebraska City, Nebraska.
(WE DO NOT SERVE THE CITY OF COUNCIL BLUFFS)
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I wish to be on the Section 8 Waiting List. Yes No
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(YOU CAN APPLY FOR BOTH WAITING LISTS)
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PUBLIC HOUSING
SIRHA owns the rental unit. You pay your portion of rent to SIRHA. We are the landlord.
SIRHA makes repairs and cleans rental unit before you move in.
You have a choice in paying your rent by the Formula Method or Flat Rent Method. Formula Method – You pay 30% of adjusted annual income for rent. Flat Rent Method – You pay the rent amount set by the Housing Authority for the bedroom size of your unit.
You pay your own utility costs and a Utility Allowance is subtracted from the amount you pay for rent.
The rental unit will be inspected annually by SIRHA.
SIRHA collects a security deposit, is monitored by State and Federal agencies, and must follow regulations.
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I wish to be on the Public Housing Waiting List. Yes No
I understand I must move or live in one of the towns listed below for Public Housing. Please check the town/towns you are interested in applying for.
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We have Public Housing Family units in:
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Creston Lamoni Leon Mt. Ayr Osceola
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We have Public Housing Elderly units in:
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Creston Corning Lenox Leon Mt. Ayr
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IMPORTANT UP-FRONT INCOME VERIFICATION NOTICE
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The Southern Iowa Regional Housing Authority is now required by the U.S. Department of Housing and Urban Development to use Up-Front Income Verification (UIV) Sources whenever possible to verify income information for program participants. UIV is the verification of income through an independent source that systematically maintains income information in computerized form for a large number of individuals.
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Current UIV resources that we may be using include the following:
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• Enterprise Income Verification System (EIV) HUD’s System provides Employment Information, Quarterly Wages, Unemployment Insurance, Social Security and Supplemental Security Income (SSI) Benefits, and National Directory of New Hires (NDNH).
• Tenant Assessment Subsystem (TASS) – HUD’s online system for Social Security (SS) and Supplemental (SSI) information.
• State Wage Information Collection Agencies (SWICA’s)
• State systems for the Temporary Assistance for Needy Families (TANF) Program
• Credit Bureau Information (CBA) credit reports
• International Revenue Services (IRS)
• Private sector databases (e.g. The Work Number)
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We will use additional UIV resources as they become available. This will be done before, during and/or after examination and/or re-examination of household income as necessary to ensure participants are reporting and paying rent on the appropriate amount of income.
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It is important to note that UIV data will only be used to verify a participant’s eligibility for participation in a rental assistance program and to determine the level of assistance the participant is entitled to receive.
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You are required to disclose and report all sources of money (income) you and any member of your family receives. Failure to disclose and report sources of income is FRAUD. The consequences of not reporting all sources of money (income) may include:
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• Termination of rent assistance and eviction
• Criminal prosecution, imprisoned up to 5 years and/or fined up to $10,000.
• Immediate repayment for any excess rental subsidy you received.
• Prohibited from receiving future rental assistance.
• Any other appropriate remedy.
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Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants
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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.
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Applicant Name: Malling Address:
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Phone: Cell Phone:
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Name of Additional Contact Person or Organization :
Malling Address: Email:
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Relationship to Applicant:
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Reason for Contact: (Check all that apply)
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Emergency Assist with Recertification Process
Unable to contact you Change in lease terms
Termination of rental assistance Change in house rules
Eviction from unit Other:
Late payment of rent
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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.
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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.
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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.
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The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520). The public reporting burden is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the obligation to require housing providers participating in HUD’s assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in the application for occupancy the name, address, telephone number, and other relevant information of a family member, friend, or person associated with a social, health, advocacy, or similar organization. The objective of providing such information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any delivery of services or special care to the tenant and assist with resolving any tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and maintained as confidential information. Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and management controls that prevent fraud, waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless the collection displays a currently valid OMB control number.
Privacy Statement: Public Law 102-550, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be used by HUD to protect disbursement data from fraudulent actions.
Form HUD- 92006 (05/09)
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U.S. Department of Housing and Urban Development
Office of Inspector General
November 2004
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Things You Should Know
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Don’t risk your chances for Federally assisted housing by providing false, incomplete, or inaccurate information on your application forms.
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Purpose: This is to inform you that there is certain information you must provide when applying for assisted housing. There are penalties that apply if you knowingly omit information or give false information.
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Penalties for Committing Fraud:
The United States Department of Housing and Urban Development (HUD) places a high priority on preventing fraud. If your application or recertification forms contain false or incomplete information, you may be:
• Evicted from your apartment or house:
• Required to repay all overpaid rental assistance you received:
• Fined up to S 10,000:
• Imprisoned for up to 5 years; and/or
• Prohibited from receiving future assistance.
Your State and local governments may have other laws and penalties as well.
Asking Questions:
When you meet with the person who is to fill out your application, you should know what is expected of you. If you do not understand something, ask for clarification. That person can answer your question or find out what the answer is.
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Completing The Application:
When you answer application questions, you must include the following information:
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Income:
• All sources of money you or any member of your household receive (wages. welfare payments, alimony, social security, pension, etc.):
• Any money you receive on behalf of your children (child support, social security for children, etc.);
• Income from assets (interest from a savings account, credit union, or certificate of deposit: dividends from stock, etc.);
• Earnings from second job or part time job;
• Any anticipated income (such as a bonus or pay raise you expect to receive)
Assets:
• All bank accounts, savings bonds, certificates of deposit, stocks, real estate, etc.. that are owned by you and any adult member of your family’s household who will be living with you.
• Any business or asset you sold in the last 2 years for less than its full value, such as your home to your children.
• The names of all of the people (adults and children) who will actually be living with you, whether or not they are related to you.
Signing the Application:
• Do not sign any form unless you have read it, understand it, and are sure everything is complete and accurate.
• When you sign the application and certification forms, you are claiming that they are complete to the best of your knowledge and belief. You are committing fraud if you sign a form knowing that it contains false or misleading information.
• Information you give on your application will be verified by your housing agency. In addition, HUD may do computer matches of the income you report with various Federal, State, or private agencies to verify that it is correct.
Recertifications:
You must provide updated information at least once a year. Some programs require that you
report any changes in income or family/household composition immediately. Be sure to ask
when you must recertify. You must report on recertification forms:
• All income changes, such as increases of pay and/or benefits, change or loss of job and/or benefits, etc., for all household members.
• Any move in or out of a household member; and,
• All assets that you or your household members own and any assets that was sold in the last 2 years for less than its full value.
Beware of Fraud:
You should be aware of the following fraud schemes:
• Do not pay any money to file an application;
• Do not pay any money to move up on the waiting list;
• Do not pay for anything not covered by your lease;
• Get a receipt for any money you pay; and,
• Get a written explanation if you are required to pay for anything other than rent (such as maintenance charges).
Reporting Abuse:
If you are aware of anyone who has falsified an application, or if anyone tries to persuade you to make false statements, report them to the manager of your complex or your PHA. If that is not possible, then call the local HUD office or the HUD Office of Inspector General (OIG) Hotline at (800) 347-3735. You can also write to:
HUD-OIG HOTLINE, (GFI) 451 Seventh Street, S.W., Washington, DC. 20410.
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HUD- 1140-OIG THIS DOCUMENT MAY BE REPRODUCED WITHOUT PERMISSION
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PLEASE NOTE: YOU WILL RECEIVE A CONFIRMATION EMAIL AFTER YOU SUBMIT YOUR PREAPPLICATION.
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WE REQUIRE YOU SEND US A COPY OF ANY OF OUR PREFERENCES YOU MAY QUALIFY FOR AT THIS TIME.
****** SEE INFORMATION ABOVE ******
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IT IS VERY IMPORTANT YOU FOLLOW UP WITH THIS TO PROCESS YOUR APPLICATION FOR RENT ASSISTANCE.
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EMAIL ADDRESS:
SIRHA 219 N. Pine St. Creston, Iowa 50801 Ph. 641-782-8585 Site Designed By: three C design