Housing Authority of Salt Lake City

HOUSING AUTHORITY OF SALT LAKE CITY

HOUSING APPLICATION

Section 8 Programs: Special Projects:Wait List Closed for Section 8 Voucher

Jefferson Circle (2bdrm)
Moderate Rehab. (studio - 2 bdrm)
Sunrise - Project Based Voucher (studio - 1 bdrm)

Public Housing:

Palmer Court - Project Based Voucher (studio - 1 bdrm)
Senior (1 bdrm)
Other Special Programs:(by referral only, please specify)

Personal Information

First Name
Last Name
Home Phone	ext
Email Address

Current Residence:

Street Address with Apt. #,

City, State and zip code.
,

Work/Msg. Phone ext

Mailing Address (if different than above)

Street Address with Apt. #,

City, State and zip code.
,

You must keep a current mailing 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: Check one: Married Single Widow/Widower Divorced
Check one: Hispanic Non-Hispanic
Check one: White African Am Am Indian Asian Pac/Isl Other
Language Used in Household:

Disabilities Is the Head or Co-Head of household disabled as defined by the Social Security Act? Yes No
If yes who? Do you need a Wheelchair unit only? Yes No
Do you or anyone in your household require a reasonable accommodation? Yes No
If yes explain
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
		Co-head or Spouse

Do you expect a change in your family size? Yes No If Yes 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)

Name of Household Member	Source of income:	Gross Amount per year	Employment income per hour	Employment hours per week

ASSETS Do you or any household memeber own or have an interest in real estate, boat, and/or mobile home? Yes NO
Have you sold any real estate in the last two years? Yes No
Do you own any stocks or bonds? Yes No
Do you have a checking and/or savings account? Yes No
If Yes to any of these questions, give bank, account number and amounts below.

Bank	Account Number	Amount

PREVIOUS GOVERNMENT HOUSING ASSISTANCE AND INFORMATION Are you currently or have you ever received a housing subsidy from any Federal Program? Yes No
If Yes list agency, time and place: Agency: When: Where:

Agency	When	Location

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

Agency	Amount

Have you ever participated in a violent crime? Yes No
If yes please explain.
Have you ever participated in illegal drug use? Yes No
If yes please explain.

Please provide the contact information of a friend/relative who can be reached in case of emergency

Full Name	Address	Phone	Relationship

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.

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
Family, Elderly or Disabled person that is a victim of Domestic Violence within the past 12 months. (Verifications will be required when your name reaches the top of the waiting list)
Homeless individual with disabilities. ( This is for Project Based Vouchers with case management required)

HOUSING ADVOCACY RELEASE

Please complete ONLY if you want another individual/agency to help you with housing issues.

I, agree to allow to serve as an advocate for me regarding housing issues. I authorize this individual or agency to discuss my personal information with the Housing Authority of Salt Lake City as long as this information pertains to housing matters.

Client Information			Housing Advocate:
Applicant Name			Advocate Name
Applicant Social Security #			Full Address
Date			Telephone Number

AUTHORIZATION OF THE RELEASE OF INFORMATION

Rev 4/16/2007 (lt)

Housing Authority of Salt Lake City

Organization requesting release of Information:

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 Collages

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.

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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.

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Conditions:

By selecting "Yes" 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.
Yes No

I agree that photocopies of this information may be used for the purposes stated above.
Yes No

I understand that applying for Housing Assistance requires a Criminal Background Check and authorize the PHA the check to be done.
Yes No

YOU MUST AGREE TO THE THREE CONDITIONS ABOVE IN ORDER FOR YOUR APPLICATION TO PROCESS

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***YOU MUST AGREE TO THE THREE CONDITIONS ABOVE IN ORDER FOR YOUR APPLICATION TO PROCESS***

YOU MUST AGREE TO THE THREE CONDITIONS ABOVE IN ORDER FOR YOUR APPLICATION TO PROCESS