City of Ames CDBG Renter Affordability Program Deposit and/or First Month s Rent Assistance CHECKLIST FOR APPLICATION SUBMITTAL

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1 City of Ames CDBG Renter Affordability Program Deposit and/or First Month s Rent Assistance The purpose of this program is to assist low income households with up to $1, towards their rental deposit and/or first month s rent. This program is limited to the city limits of Ames and subject to the availability of funds. CHECKLIST FOR APPLICATION SUBMITTAL Please check items as completed and submit this checklist along with your application. APPLICATIONS WILL NOT BE ACCEPTED WITHOUT Application Form Release of Information for All Adult (Age 18+) Household Members (COPY MORE IF NEEDED) Declaration of Citizenship Documentation of ALL Household Income and Assets Including but not Limited to: Employment Self-Employment Unemployment FIP Child Support Social Security/SSI Veteran s Benefits Assets Last Three (3) Months of Pay Stubs OR Verification of Employment Form (COPY MORE IF NEEDED) Last Two (2) Years Filed Tax Returns Workforce Development Center Weekly Benefit Amount Department of Human Services Notice of Decision Last Three (3) Months of Payment Records Including Amounts Retained by the State Social Security Award Letter Veteran s Affairs Award Letter Current Bank Statement(s) OR Verification of Assets Form (COPY MORE IF NEEDED) Current State-Issued Driver s License/ID OR Passport for All Adult (Age 18+) Household Members Social Security Card for All Adult (Age 18+) Household Members ADDITIONALLY, SECTION 8 VOUCHER HOLDERS REQUIRE Section 8 Housing Choice Voucher PROGRAM GUIDELINES AVAILABLE AT: QUESTIONS? PLEASE CALL OUR HOUSING HOTLINE: Voucher Worksheet Applications can be mailed, dropped off, or faxed to: City of Ames Department of Planning & Housing PO Box 811 / 515 Clark Avenue, Room 214, Ames, IA (fax) Complete applications will be processed on a first come, first served basis. If you believe that you have been discriminated against, you may call the Fair Housing & Equal Opportunity National Toll- Free Hotline at or locally to the Ames Human Relations Commission at

2 City of Ames CDBG Renter Affordability Program Deposit and/or First Month s Rent Assistance APPLICATION FORM PLEASE ANSWER EVERY QUESTION. USE THE CORRECT LEGAL NAME FOR EACH HOUSEHOLD MEMBER AS IT APPEARS ON THEIR SOCIAL SECURITY CARD. ALL ADULT HOUSEHOLD MEMBERS MUST SIGN ON THE BACK, CERTIFYING THE INFORMATION PERTAINING TO THEM. IF YOU HAVE ANY QUESTIONS OR NEED HELP FILLING OUT THIS FORM, PLEASE CONTACT OUR HOUSING HOTLINE AT (515) This program provides eligible low income households with up to $1, towards rental deposits and/or first month s rent. Type of Assistance Requested: Rental Deposit AND/OR First Month s Rent Address of Proposed Unit (If Known At This Time) City, State, Zip Anticipated Move-In Date Property Owner Will you be receiving additional help with the rental deposit or first month s rent from another source (i.e. another agency, family, friend, etc.)? Yes No If yes, please list the name of the source and the type and amount of assistance: Will you be receiving ongoing help with the rent (i.e Section 8 or another form of rent subsidy)? Yes No If yes, please list the name and address of the agency and type of assistance: Part 1: Head of Household (HOH) Information Last Name, First Name, Middle Initial (MI) Current Address* City, State, Zip Phone Number (Include Area Code) Background Information Have a Dependent Marital Status Single (Check All Boxes That Apply) Disabled (Check Only 1 Box) Married Elderly (age 62+) Pregnant Veteran or Surviving Spouse of a Veteran Live in a Homeless Shelter or Transitional Housing None of the Above Divorced Separated Widowed Race White Ethnicity Hispanic (Check Only 1 Box) Black/African American (Check Only 1 Box) Not Hispanic Asian American Indian/Alaskan Native Native Hawaiian/Other Pacific Islander American Indian/Alaska Native & White Asian/White Black/African American & White American Indian/Alaskan Native & Black/African American Other Multi-Racial Language Do you speak English as your primary language? Yes No IF NO, what is your primary language? Do you read, write, speak, or understand English well? Yes No * If using General Delivery or a PO Box, must also include physical address (with the exception of ACCESS). Part 2: Household Information List the HOH first and then all additional household members. List the relationship of each person to the HOH. Attach additional sheet, if needed. Last Name, First Name, MI Relationship Date of Birth Age Sex Social Security # HOH SEE BACK OF SHEET

3 Part 3: Household Income List ALL money earned or received by everyone in your household. This includes money from wages (including temporary or seasonal), self-employment/business, unemployment, financial assistance (i.e. student loans/grants, work study), child support payments, contributions, Social Security Disability Payments, SSI, Worker's Compensation, retirement benefits, ADC/FIP, Veteran s benefits, rental property income, stock dividends, income from bank accounts, alimony, and all other sources. Attach additional sheet, if needed. Household Member Type of Income Name and Address of Employer or Other Source of Income Gross/Mo Does any agency or person outside of your household pay for any of your bills, give you money, or provide subsidy? Yes No IF YES, please explain Part 4: Household Assets List ALL sources of household assets including, but not limited to: Checking, Savings, Other Bank Accounts, Stocks, Bonds, CDs, Trusts, and Real Estate. Attach additional sheet, if needed. Household Member Type of Asset Name and Address of Bank or Other Source Asset Balance 1. Does any household member own any stocks or bonds? Yes No 2. Does any household member own or have an interest in real estate and/or a mobile home? Yes No Part 5: Household Eligibility 1. Has any household member used any name(s) other than the one currently being used (i.e. maiden name, former married name, alias)? Yes No IF YES, please explain: 2. Is any household member a college student? Yes No IF YES, please list the household member s name: Is this household member claimed as a dependent on parents Income Tax return? Yes No 3. Has any household member ever received deposit assistance from this program? Yes No IF YES, please list the household member s name: 4. Has any household member committed fraud on any program administered by the City of Ames Housing Division? Yes No IF YES, please explain (include the name of the household member and the name of the program): PLEASE NOTE: A background check will be completed to determine if anyone in the household 1) is required to register as a sex offender, pursuant to any state sex offender registration law and 2) has been charged with, arrested for, or convicted of a drug-related or violent criminal activity in the last twelve (12) months. 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. I/We certify that the information given to the City of Ames Housing Division on household composition, income, assets, and eligibility is accurate and complete to the best of my/our knowledge and belief. I/We understand that false statements or information are punishable under Federal law. I/We also understand that false statements or information are grounds for denial of my/our application for the CDBG Renter Affordability Program. Additionally, if falsification or misrepresentation of any information in this application is found after receiving the assistance, I/we understand that I/we will be subject to legal action by the City of Ames. Signature of Head of Household Date Signature of Spouse Date Signature of Other Adult Date Signature of Other Adult Date Alternate Contact Person: Case Worker Friend Neighbor Relative Other Name Address City, State, Zip Phone Number (Include Area Code) Effective July 2015 Office Use Only: RECEIVED DATE STAMP COMPLETE: Yes No Office Use Only: COMPLETE DATE STAMP

4 Department of Planning & Housing Community Development Block Grant Program APPLICANT S AUTHORIZATION FOR RELEASE OF INFORMATION Name of Client: Maiden or previous name: Birth date: Social Security Number: I. AUTHORIZATION FOR RELEASE OF INFORMATION The undersigned hereby authorizes any or all of the following resources to release, disclose, and/or deliver to the City of Ames Department of Planning and Housing information related to the above named client for the purposes of determining eligibility and/or continued participation in the CDBG Renter Affordability Program: Employers State/County Human Service Agencies (i.e. Social Security, Human Services, Case Managers, etc.) Financial Institutions Relatives/Friends Property Managers/Owners Utility Companies Law Enforcement/Correctional Agencies Educational Institutions Central Iowa Regional Housing Authority (CIRHA) Other Other I understand that I have a right to inspect the disclosed information at any time by making inquiry to the above named resources at any time. This Authorization will automatically expire 1 year from the date of signature, except as specified: (list specific number of days or months). I understand that I may revoke this Authorization at any time, except to the extent that action has already been taken in reliance upon it, by giving written notice to the City of Ames Department of Planning and Housing. A photocopy or exact reproduction of the signed Authorization shall have the same force and effect as the original. I hereby authorize the release of information as indicated above. (Signature of Client) (Date) (Street Address) (City) (State) (Zip Code) (Relationship, if not Client) 515 Clark Avenue P.O. Box 811 Ames, IA Phone: Fax: TDD:

5 PART 1: APPLIES TO ALL FAMILY MEMBERS City of Ames Community Development Block Grant Renter Affordability Program DECLARATION OF CITIZENSHIP Each person who will benefit under the CDBG Renter Affordability Program must either be a citizen or national of the United States, or be a noncitizen who has eligible immigration status that qualifies them for assistance as determined by the U.S. Department of Housing and Urban Development and the U.S. Immigration and Naturalization Service. One box on this form must be checked for each family member indicating status as a citizen or a national of the United States, or a noncitizen with eligible immigration status. Family members residing in the household to be assisted who do not claim to be a citizen or national of the United States, or do not claim to be a noncitizen with eligible immigration status, should not check any box. All adults must sign where indicated. For each child who is not 18 years of age, the form must be signed by an adult member of the family residing in the dwelling unit who is responsible for the child. Use blank lines to add family members who are not listed. First Name Last Name Age I am a citizen or national of the U.S. I am a noncitizen with eligible immigration status or or or or or or Signature of Adult listed to the left, or Signature of Guardian for Minors WARNING Title 18 US Code Section 1001 states that a person is guilty of a felony for knowingly and willingly making a false or fraudulent statement to any department or agency of the United States. If this form contains false or incomplete information, you may be required to repay all overpaid rental assistance you received, fined up to $10,000, imprisoned for up to 5 years, and/or prohibited from receiving future assistance. NOTE: Family members who have checked a box indicating that they are a noncitizen with eligible immigration status MUST complete Part 2 of this form. PART 2: APPLIES TO NONCITIZEN FAMILY MEMBERS ONLY All family members who have claimed eligible immigration status on Part 1 of this form must provide this office with an original of one of the following documents: (1) Form I-551, Alien Registration receipt Card (2) Form I-94, Arrival-Departure Record with appropriate annotations or documents (3) Form I-688, Temporary Resident Card (4) Form I-688B, Employment Authorization Card (5) A receipt issued by the INS indicating that an application for issuance of a replacement document in one of the above-listed categories has been made and the applicant s entitlement to the document has been verified Do not mail original documents to this office. If documents are not presented and verified, your family s ability to receive assistance under the CDBG Renter Affordability Program will be denied as provided in regulations promulgated by the U.S. Department of Housing and Urban Development. HEAD OF HOUSEHOLD CERTIFICATION As head of household, I certify under penalty of perjury, that all members of my household are listed on Part 1 of this form and that members of my household who have not checked either box on Part 1 of this form do not claim to be citizens or nationals of the United States, or noncitizens with eligible immigration status. Signature Date Consent to Verify Eligible Immigration Status Each family member required to complete Part 2 of this form must sign below granting consent to verify eligible immigration status. For each child who is not 18 years of age, the form must be signed by an adult member of the family residing in the dwelling unit who is responsible for the child. First Name Last Name Age Signature of Adult listed to the left, or Signature of Guardian for Minors Office Use Only INS VERIF. # Evidence supplied with this form may be released by the City of Ames Housing Division, without responsibility for its further use or transmission, to the Immigration and Naturalization Service for purposes of verification of the immigration status of the individual or to the U.S. Department of Housing and Urban Development, as required. The U.S. Department of Housing and Urban Development is not responsible for the further use or transmission of the evidence or other information.

6 Department of Planning & Housing Community Development Block Grant Program 515 Clark Avenue PO Box 811 Ames, IA FA TDD Re: Verification of Assets To Whom It May Concern: MUST Be Completed By Financial Institution, NOT Self-Declared Please provide the information that is requested below. This information will be used only for the purpose of determining the household's eligibility for a City of Ames Community Development Block Grant (CDBG) Renter Affordability Program and will not be disclosed except in accordance with federal regulations or state law. If you have any questions, please contact a Housing Specialist at (515) APPLICANT S NAME SS# ADDRESS CITY STATE ZIP Financial Institution Name Financial Institution Address Checking Account # Current Balance: $_ Interest Rate % Savings Account # Current Balance: $_ Interest Rate % Other: (For example CDs, Money Markets, Trust Funds, Burial Fund, Stocks and/or Bonds) Current Balance: $ Interest Rate % Type of Account Current Balance: $ Interest Rate % Type of Account The information provided is accurate and current. I understand that providing false information is a violation of federal regulations and state law. Signature: Date: Printed Name and Title: Phone #:

7 Department of Planning & Housing Community Development Block Grant Program 515 Clark Avenue PO Box 811 Ames, IA FA TDD Re: Verification of Employment To Whom It May Concern: MUST Be Completed By Employer, NOT Self-Declared Please provide the information that is requested below. This information will be used only for the purpose of determining the household's eligibility for a City of Ames Community Development Block Grant (CDBG) Renter Affordability Program and will not be disclosed except in accordance with federal regulations or state law. If you have any questions, please contact a Housing Specialist at (515) APPLICANT S NAME SS# ADDRESS CITY STATE ZIP Employer Name Employer Address Employment Start Date Date of Last Employment Current Rate of Pay: Overtime Rate of Pay: $ per Hour, Day, Week, Month (Circle One) $ per Hour, Day, Week, Month (Circle One) Average # of Hours Scheduled to Work per Week: Straight time Overtime Estimated Weekly Income from Tips $ Increase in Pay During Next 12 Months? Yes No If Yes, Effective Date Anticipated Rate of Pay: $ per Hour, Day, Week, Month (Circle One) The information provided is accurate and current. I understand that providing false information is a violation of federal regulations and state law. Signature: Date: Printed Name and Title: Phone #: