Application for Housing

HOUSING AUTHORITY OF SALT LAKE CITY
HOUSING APPLICATION

Housing Authority of Salt Lake City
1776 S. West Temple
Salt Lake City, UT 84115
(801) 487-2161
Fax (801) 487-3641
TDD (801) 487-3361

For Office Use Only
Revised 08/2012

Input By:
Bedrooms:
Client No:
Date Input:

Please mark the program(s) you are applying for

Section 8 Programs:

Public Housing:

Section 8 Housing Choice Voucher

Senior (55 and older-1 bdrm)

Moderate Rehab. (studio - 2 bdrm)

Rendon Terrace (62 and older-1bdrm)

Sunrise - Project Based Voucher (studio - 1 bdrm)

Palmer Court - Project Based Voucher (studio - 1 bdrm)

Taylor Springs - Project Based Voucher (62 and older-1 bdrm)

New Construction Program:

Jefferson Circle (2 bdrm)

Other Special Programs:(by referral only, please specify)

PLEASE PRINT - ANSWER ALL QUESTIONS. IF APPLICATION IS NOT COMPLETE, IT WILL BE SENT BACK.

Name

Home Phone

Current Address

Work Phone

Mailing Address

You must keep a current address with us at all times.

Please list any other names you have used (Maiden or Other):

The following information is requested in compliance with HUD regulations:

Check one: Married Single Widow/Widower Divorced Separated

Check one: Hispanic or Latino Yes No

Check one: White Black or African American American Indian or Alaska Native Asian
Native Hawaiian or Other Pacific Islander other

Language Used in Household:

*Disabilities
Do you or a member of your household have a disability? Yes No If yes, who
Do you or a member of your household require a reasonable accommodation? Yes No If yes, what is the accommodation?
Do you or a member of your household require a specific accessible unit (mobility/vision/hearing impaired)? Yes No
If yes, what:
*It is not mandatory for you to answer the above question, but it will help us to know your housing needs.

FAMILY COMPOSITION - List all persons, including yourself, who will live in the subsidized unit with you.

Full Name of all Family Members	Social Security Number	Relationship to head	Sex	Date of Birth	Age	Place of Birth (City & State)
		Head of Household
		CoHead or Spouse

Do you expect a change in your family size? Yes No Expected change & Date:

TOTAL HOUSEHOLD INCOME:

List all money earned or received by everyone living in your household. This includes money from wages, self-employment, child support, contributions, Social Security, disability payments (SSI), Workman Compensation, Retirement benefits, TANF Welfare, Veterans benefits, rental property income, stock dividends, income from bank accounts, alimony, church welfare and any other sources. (If none please specify)

Household Members	Source of income	Gross Amount per year	Employment income per hour	Employment hours per week

ASSETS

Do you or any household members own or have any interest in real estate, boat, and/or mobile home? Yes No
Have you sold any real estate in the past two years? Yes No
Do you have a checking and/or savings accounts Yes No If “Yes” where:
Do you own any stocks or bonds? Yes No

PREVIOUS GOVERNMENT HOUSING ASSISTANCE AND CRIMINAL INFORMATION

Are you currently or have you ever received a housing subsidy from any Federal Program? Yes No
If “yes” list Agency: When:

Do you currently owe for damages/unpaid rent to any Federally funded housing program? Yes No
If yes, list amount and agency.

Has anyone in the household ever participated in a violent crime? Yes No If “yes” who and explain

Has anyone in the household ever participated in the use of illegal drugs? Yes No If “yes” who and explain.

Is any household member subject to a lifetime registration requirement under any state sex offender registration program?
Yes No If “yes” who:

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I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND MAY BE USED FOR THE PURPOSE OF VERIFICATION. I UNDERSTAND THAT THIS IS NOT A CONTRACT AND DOES NOT BIND EITHER PARTY. I ALSO UNDERSTAND THAT ANY CHANGES OF INCOME OR FAMILY COMPOSITION WILL BE REPORTED TO THE HOUSING AUTHORITY IN WRITING.
*******************************************************************************************

Signed:      Date:
               Head of Household
Signed:      Date:
                Co-Head/Other Adult

WARNING: Title 18, Section 1001 of the United States Code, states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department or agency of the United States.

*The Housing Authority complies with Section 504 of the Rehabilitation Act of 1973 in providing individuals with a disability equal access to the services, programs, and activities the Housing Authority offers. Upon request the Housing Authority will provide reasonable accommodations to individuals with disabilities. To request a reasonable accommodation; contact Camille Bowen, 504 Coordinator, Housing Authority of Salt Lake City, 1776 South West Temple, Salt Lake City, Utah 84115. VOICE: 801-428-0565 FAX: 801-487-3641 TDD: 801-487- 3361. For information on the availability of auxiliary aids contact Reed Robinson at 801-487-2161 extension 1241. All persons will be treated fairly and equally without regard to race, color, religion, sex familial status, disability or national origin in compliance with Fair Housing Act.

PROGRAMS TARGETED TO SPECIAL POPULATIONS

The Housing Authority of Salt Lake City has several rental assistance programs that are targeted to specific “special” populations. It is very important to mark ALL that apply to your situation.
Head of House or Co-head disabled.
Veteran
Homeless individual with disabilities. ( This is for Project Based Vouchers with case management required at Palmer Court and Sunrise properties)

AUTHORIZATION OF THE RELEASE OF INFORMATION

Rev 4/16/2007 (lt)

Housing Authority of Salt Lake City

Housing Authority of Salt Lake City 1776 S. West Temple Salt Lake City, UT 84115

Purpose:

The U.S. Department of Housing and Urban Development (HUD) and the above-named organization may use this authorization and the information obtained with it, to administer and enforce program rules and policies.

Authorization:

I authorize the release of any information (including documentation and other materials) pertinent to eligibility for or participation under any of the following programs:

Low-Income Rental Public Housing

Section 8 Housing Assistance Payments’ Program

I authorize the above-named organization and HUD to obtain information about me or my family that is pertinent to eligibility for or participation in assisted housing programs.

I authorize only HUD, or a Public Housing Agency (PHA) to obtain information on wages, or unemployment compensation from State Employment Securities Agencies.

I understand any Criminal History Record or Police incident report(s) can be released to any adult receiving Housing Assistance who may be directly effected. I hereby release the Housing Authority from any liability that may result from the receipt or use of any Criminal History Record or Police incident report(s).

Information-Covered Inquiries may be made about:
Child Care Expenses
Credit History
Criminal Activity
Family Composition
Employment, Income, Pensions and Assets
Federal, State, Tribal or Local Benefits
Handicapped Assistance Expenses
Identity and Marital Status
Medical Expenses
Social Security Numbers
Residences and Rental History

Individuals or Organizations That May Release Information:

Any individual or organization including any governmental organization may be asked to release information. For example, information may be requested from:

Banks and Other Financial Institutions
Courts, Credit Bureaus
Law Enforcement Agencies Employers, Past and Present Landlords
Providers of:
Alimony, Child Care Child Support, Credit Handicapped Assistance
Medical Care
Pensions/Annuities
Schools and Colleges
U.S. Social Security Administration U.S. Department of Veterans Affairs Utility companies
Welfare Agencies

Computer Matching Notice and Consent: I agree that a Public Housing Agency, or HUD may conduct computer matching programs with other governmental agencies including Federal, State, Tribal, or local agencies. The governmental agencies include:

U.S. Office of Personnel Management
U.S. Social Security Administration
U.S. Department of Defense
U.S. Postal Service
State Employment Security Agencies
State Welfare and Food Stamp Agencies
Enterprise Income Verification (EIV)

The match will be used to verify information supplied by the family.

By signing below I agree to allow the PHA to discuss income information with any or all household members who act as representative(s) of our family.

Conditions:
I agree that photocopies of this information may be used for the purposes stated above.

If I do not sign this authorization, I also understand that my Housing assistance may be denied or terminated.

Head of Household Name	Signature	Date	Social Security #	Date of Birth
Head of Household Name	Signature	Date	Social Security #	Date of Birth
Head of Household Name	Signature	Date	Social Security #	Date of Birth
Head of Household Name	Signature	Date	Social Security #	Date of Birth

YOU MUST COMPLETE OTHER SIDE
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)