INITIAL PRELIMINARY APPLICATION Housing Choice Voucher (Section 8) NOTE: USE LEGAL NAMES ONLY Head of Household (Last/First/Middle) Social Security #

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1 INITIAL PRELIMINARY APPLICATION Housing Choice Voucher (Section 8) Public Housing NOTE: USE LEGAL NAMES ONLY Head of Household (Last/First/Middle) Sex Social Security # of Birth Race Ethnicity (Hispanic/ Non-Hispanic) Source of Income Other Adults (Last/First/Middle) Sex: Relationship to Head Social Security # of Birth Race Ethnicity (Hispanic/ Non-Hispanic) Source of Income Minors (Last/First/Middle) Sex Relationship to Head Social Security # of Birth Race Ethnicity (Hispanic/ Non-Hispanic) Birthplace Enter your present street address City, State Zip How long? Day phone ( ) Evening phone ( ) Enter your present mailing address: City, State Zip Landlord s Name: Phone #( ) Rent: Emergency Contact: Name Day Phone( ) Evening phone ( ) NOTICE: YOU ARE REQUIRED TO NOTIFY THE HOUSING AUTHORITY (IN WRITING) OF ANY CHANGE OF ADDRESS. IF WE CANNOT CONTACT YOU AT THE ABOVE ADDRESS; YOUR NAME MAY BE REMOVED FROM THE WITING LIST, AND YOU WILL HAVE TO RE-APPLY. Is English your primary language Yes No If No, please list primary language_. Do you have limited ability to read, write, and understand English? Yes No Do you claim any of the following preferences? If yes, please check the appropriate box. Paying more than 50% of monthly income towards rent. Living in substandard facility Involuntarily displaced Mobility Impairment Hearing Impairment Sight Impairment Working Other Have you ever violated a previous family obligation in connection with a HUD program? Yes No Have you ever engaged in the use/possession of drugs? Yes No Do you owe any money to a Public Housing Authority? Yes No Has any household member listed on this application ever lived in another state besides Georgia since they turned the age of 18? Yes No If yes, please list who and what state they lived in. I DO HEREBY CERTIFY THAT ALL INFORMATION I HAVE PROVIDED IS COMPLETE AND ACCURATE. Signature Time LLG

2 FLOYD COUNTY, GEORGIA Tim Burkhalter Sheriff OFFICE OF THE SHERIFF Tom Caldwell, IV Chief Deputy I hereby authorize the Floyd County Sheriff s Office to release any and all criminal history record information pertaining to me which may be in the files of any local and/or state criminal justice agency. I do hereby release the Floyd County Sheriff s Office and all personnel from any damages because of/or resulting from furnishing such information. Please indicate below if this Criminal History check is for employment in any of the following areas: Public/Private School, Day Care, Child Welfare, any type of Child Care Mentally Ill and/or Mentally Retarded Nursing home, Personal Care Home or other type of elderly care Criminal Justice Employment General Employment or Housing Please Print Clearly Last Name: First Name: Full Middle Name: of Birth: Social Security: Place of Birth: Any Last Name(s) Also Known As: Address: City: State: Sex: Male Female Race: For Official use Only Do Not Write in this Space No Record Found (No Printout Attached) See Attached Record Signature: : Agency Signature: : USE OF SOCIAL SECURITY NUMBER ON BACKGROUND CHECKS We may ask you to provide us with your social security number as part of the application process. YOU ARE NOT REQUIRED TO DO SO. While you are not required to do so, it may be of help in confirming your identity and expediting your application. Failure to provide your social security number might delay the processing of your background check. It will be used ONLY for the purpose of confirming your identity with the other state, federal, and governmental agencies for data collection. Thanks, Sheriff Tim Burkhalter Not Official Without Seal

3 Is the Landlord a Relative? Yes No Is the Landlord a Relative? Yes No Is the Landlord a Relative? Yes No Is the Landlord a Relative? Yes No SCREENING QUESTIONNAIRE Applicant s Name: Present Address: 1. Has anyone listed on this application ever lived in public housing? Yes No If yes, please list below: Housing Authority Name: Phone #_ s: From To Address: City: State Zip Code Lease in Name of: Reason for Moving: 2. List names, addresses and phone numbers of last five addresses beginning with your most recent address. Please note if the landlord is a relative. You must provide a phone number for the landlord. Landlord is the person that receives the rent for the apartment/house, not the person that you live with. A. s: From To Address Landlord s Name Phone #_ City State Zip Code Lease in Name of: Reason for Moving: B. s: From To Address Landlord s Name Phone #_ City State Zip Code Lease in Name of: Reason for Moving: C. s: From To Address Landlord s Name Phone #_ City State Zip Code Lease in Name of: Reason for Moving: D. s: From To Address Landlord s Name Phone #_ City State Zip Code Lease in Name of: Reason for Moving:

4 Is the Landlord a Relative? Yes No Screening Questionnaire Page Two Applicant Name: E. s: From To Address Landlord s Name Phone #_ City State Zip Code Lease in Name of: Reason for Moving: 3. Have you ever been evicted from a residence? Yes No If yes, please list landlord s name, address, phone number and reason. Name Address Phone # City State Zip Code Reason 4. Have any family members or expected visitors been banned from NWGHA properties? Yes No If yes, list below: Name Relation Area s 5. Have you ever been convicted of a felony or misdemeanor, including traffic violations? Do not include parking violations. Yes No If yes, list date, place and charge of conviction: 6. Give names, addresses and phone numbers of three (3) persons who can provide a reference. Reference must be 25 years or older and have known you for five (5) years or more. (Do not include relatives.) A. Name Phone # Address City State Zip Code B. Name Phone # Address City State Zip Code C. Name Phone # Address City State Zip Code 7. Give names, addresses, and phone numbers of two (2) persons who were your neighbor. A. Name Phone # Address City State Zip Code B. Name Phone # Address City State Zip Code WARNING: PENALITIES FOR MISUSING APPLICANT AND RESIDENT INFORMATION: Title18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false and fraudulent statements to any department of the United States Government. HUD, the PHA and any owner (or any employee of HUD, the PHA or the owner) may be subject to penalties for unauthorized disclosures or improper use of information collected from the applicant or resident. Any persons 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 45,000. 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, the PHA or the owner responsible for the unauthorized disclosure or improper use. Applicant Signature Revised LLG

5 To: RE: PAST LANDLORD S VERIFICATION FORM I,, hereby consent to the release of the following information. I am aware that I do not have to sign this consent form if I was not advised of the person(s) providing and/or receiving this information. Applicant Signature The above named individual (applicant) has applied for low-income housing with Northwest Georgia Housing Authority and has given your name/agency as a previous landlord. Northwest Georgia Housing Authority is required to determine an applicant s past record of meeting his/her financial obligations of paying rent; whether the applicant has a record of disturbance of his/her neighbors; whether the applicant has a living or housekeeping habit that may affect the health, safety, and welfare of other residents. (Please answer questions on back of this page.)

6 Applicant s Name: 1. Does (did) the applicant have a record of paying rent promptly? Yes No If no, please explain: 2. Does the applicant owe your money? Yes No If yes, please list amount: $. Have arrangement been made for repayment of balance owed? Yes No 3. To your knowledge, does (did) the applicant have a record of Yes No disturbing his/her neighbors? If yes, please describe: 4. Did the applicant damage your property? Yes No If yes, please explain: 5. To your knowledge, did the applicant have living or housekeeping habits that would affect the health, safety and welfare of other residents? Yes No If yes, please explain: 6. How long did the applicant reside at? Years Months Move In Move Out 7. To your knowledge, was the applicant or any member of his/her household involved in any criminal activities? Yes No If yes, please explain: 8. Would you lease to this applicant again? Yes No If no, please explain: 9. If former public housing resident, are any community service hours owed? Yes No If yes, how many? WARNING: PENALITIES FOR MISUSING APPLICANT AND RESIDENT INFORMATION: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD, the PHA and any owner (or any employee of HUD, the PHA or the owner) may be subject to penalties for unauthorized disclosures or improper use of information collected from the applicant or resident. Any person who knowingly or willfully requests, obtains or discloses any information under false pretense 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, the PHS or the owner responsible for the unauthorized disclosure or improper use. Signature Agency/Authority (if Applicable) Title Revised LLG

7 To: RE: PERSONAL REFERENCE CHECK FORM I,, hereby consent to the release of the following information. I am aware that I do not have to sign this consent form if I was not advised of the person(s) providing and/or receiving this information. Applicant Signature The above named individual (applicant) has applied for low-income housing with Northwest Georgia Housing Authority and has given your name as a personal reference. Northwest Georgia Housing Authority is required to determine whether the applicant has a record of disturbance of his/her neighbors; whether the applicant has a living or housekeeping habit that may affect the health, safety, and welfare of other residents. 1. To your knowledge, does (did) the applicant have a current record of Yes No disturbing his/her neighbors? If yes, please describe: 2. Have you visited this applicant s current residence? Yes No If yes, please rate the housekeeping habits as follows: Excellent Good Fair Poor If less than Good please explain: 3. To your knowledge, is the applicant or any member of his/her household involved in any criminal activities? Yes No If yes, please explain: 4. How long have you known this applicant? years months Would you recommend this resident to be housed with NWGHA? Yes No If yes, please explain:. If no, why not: WARNING: PENALITIES FOR MISUSING APPLICANT AND RESIDENT INFORMATION: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD, the PHA and any owner (or any employee of HUD, the PHA or the owner) may be subject to penalties for unauthorized disclosures or improper use of information collected from the applicant or resident. Any person who knowingly or willfully requests, obtains or discloses any information under false pretense 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, the PHS or the owner responsible for the unauthorized disclosure or improper use. Signature Agency/Authority (if Applicable) Title Revised LLG

8 Dear Applicant, Please be advised as part of the screening process, all information furnished on the above date will be verified prior to admission. Your past records as a resident, rent paying habits and other factors will help us determine whether or not you may have an adverse influence on the health and safety of other residents. You will be notified by mail of the results. Should you have any questions you may contact the Admissions Office at Sincerely, NWGHA Representative Signature By my signature below, I acknowledge that I have read the above statement and had it read to me and understand the content of such. Applicant Signature Printed Name of Applicant Revised LLG

9 No Preference First available AMP 1 Central Rome Area Highrise #1 Hardy Apartments elderly Highrise #2 Frost Apartments elderly Highrise #3 Barron Apartments - elderly SITE BASED WAITING LIST (Please check site(s) of preference) AMP 2 East Rome Area John Graham Homes AMP 3 North Rome Area Park Homes Main High Apartments (Green & Gold) AMP 5 Rockmart Area Booker T. Washington Homes Eastview Homes Westview Homes AMP 4 West Rome Area Willingham Village AMP 6 West Rome Area Willingham at Division Street No Pets Allowed. (non smoking & income only) Do you smoke? Yes No Do you have income? Yes No AMP 7 South Rome Area AMP 8 Central Rome Area Pennington Place elderly Hight Homes at Avenue B No Pets Allowed. No Pets Allowed. (non smoking & income only) (non smoking & income only) Do you smoke? Yes No Do you smoke? Yes No Do you have income? Yes No Do you have income? Yes No AMP 9 West Rome Area AMP 10 Rockmart Area Village Green Jackson Street Apartments No Pets Allowed. No Pets Allowed. (non smoking & income only) (non smoking & income only) Do you smoke? Yes No Do you smoke? Yes No Do you have income? Yes No Do you have income? Yes No No preference of selections. If selecting more than one site, please list sites based on 1 st, 2 nd, and 3 rd choice or No preference of selections. First Choice AMP Second Choice AMP Third Choice AMP Applicant Signature NWGHA Representative Signature Revised LLG 10

10 AUTHORIZATION For Release of Information CONSENT I authorize and direct any Federal, State, or local agency, organization, business, or individual to release to Northwest Georgia Housing Authority any information or materials needed to complete and verify my application for participation, and/or to maintain my continued assistance under the Section 8, Rental Rehabilitation, Low-Income Public and Indian Housing, and/or other housing assistance programs. I understand and agree that this authorization or the information obtained with its use may be given to and used by the Department of Housing and Urban Development (HUD) in administering and enforcing program rules and polices. INFORMATION COVERED I understand that, depending on program policies and requirements, previous or current information regarding my household or me may be needed. Verifications and inquires that may be requested, include but are not limited to: Identify and Marital Status Employment, Income and Assets Residences and Rental Activity Medical or Child Care Allowances Credit and Criminal Activity Social Security Numbers I understand that this authorization cannot be used to obtain any information about me that is not pertinent to my eligibility for and continued participation in a housing assistance program. GROUPS OR INDIVIDUALS THAT MAY BE ASKED The groups or individuals that may be asked to release the above information (depending on program requirements) include but are not limited to: Previous Landlords (including Past and Present Employers Veterans Administration Pubic Housing Agencies) Welfare Agencies Retirement Systems Courts and Post Offices State Unemployment Agencies Banks and other Financial Institutions Schools and Colleges Social Security Administration Credit Providers and Credit Bureaus Law Enforcement Agencies Medical and Child Care Providers Utility Companies Support and Alimony Providers COMPUTER MATCHING NOTICE AND CONSENT I understand and agree that HUD or the Public Housing Authority (PHA) may conduct computer-matching programs to verify the information supplied for my application or re-certification. If a computer match is done, I understand that I have a right to notification of any adverse information found and a chance to disprove incorrect information. HUD or the PHA may in the course of its duties exchange such automated information with other Federal, State, or local agencies, including but not limited to: State Employment Security Agencies; Department of Defense; Office of Personnel Management; the U.S. Postal Service; the Social Security Agency; and State welfare and food stamp agencies. CONDITIONS I agree that a photocopy of this authorization may be used for the purposes stated above. The original of this authorization is on file with the PHA. I understand I have a right to review my file and correct any information that I can prove is incorrect. SIGNATURES Head of Household (Print Name) Spouse (Print Name) Adult Member (Print Name) Adult Member (Print Name) NOTE: THIS GENERAL CONSENT MAY NOT BE USED TO REQUEST A COPY OF A TAX RETURN. IF A COPY OF A TAX RETURN IS NEEDED, IRS FORM 1506, REQUEST FOR COPY OF TAX FORM MUST BE PREPARED AND SIGNED SEPARATELY. Revised LLG

11 Authorization for the Release of Information/ Privacy Act Notice to the U.S. Department of Housing and Urban Development (HUD) and the Housing Agency/Authority (HA) U.S. Department of Housing and Urban Development Office of Public and Indian Housing PHA requesting release of information; (Cross out space if none) (Full address, name of contact person, and date) IHA requesting release of information: (Cross out space if none) (Full address, name of contact person, and date) Authority: Section 904 of the Stewart B. McKinney Homeless Assistance Amendments Act of 1988, as amended by Section 903 of the Housing and Community Development Act of 1992 and Section 3003 of the Omnibus Budget Reconciliation Act of This law is found at 42 U.S.C This law requires that you sign a consent form authorizing: (1) HUD and the Housing Agency/Authority (HA) to request verification of salary and wages from current or previous employers; (2) HUD and the HA to request wage and unemployment compensation claim information from the state agency responsible for keeping that information; (3) HUD to request certain tax return information from the U.S. Social Security Administration and the U.S. Internal Revenue Service. The law also requires independent verification of income information. Therefore, HUD or the HA may request information from financial institutions to verify your eligibility and level of benefits. Purpose: In signing this consent form, you are authorizing HUD and the above-named HA to request income information from the sources listed on the form. HUD and the HA need this information to verify your household s income, in order to ensure that you are eligible for assisted housing benefits and that these benefits are set at the correct level. HUD and the HA may participate in computer matching programs with these sources in order to verify your eligibility and level of benefits. Uses of Information to be Obtained: HUD is required to protect the income information it obtains in accordance with the Privacy Act of 1974, 5 U.S.C. 552a. HUD may disclose information (other than tax return information) for certain routine uses, such as to other government agencies for law enforcement purposes, to Federal agencies for employment suitability purposes and to HAs for the purpose of determining housing assistance. The HA is also required to protect the income information it obtains in accordance with any applicable State privacy law. HUD and HA employees may be subject to penalties for unauthorized disclosures or improper uses of the income information that is obtained based on the consent form. Private owners may not request or receive information authorized by this form. Who Must Sign the Consent Form: Each member of your household who is 18 years of age or older must sign the consent form. Additional signatures must be obtained from new adult members joining the household or whenever members of the household become 18 years of age. Persons who apply for or receive assistance under the following programs are required to sign this consent form: PHA-owned rental public housing Turnkey III Homeownership Opportunities Mutual Help Homeownership Opportunity Section 23 and 19(c) leased housing Section 23 Housing Assistance Payments HA-owned rental Indian housing Section 8 Rental Certificate Section 8 Rental Voucher Section 8 Moderate Rehabilitation Failure to Sign Consent Form: Your failure to sign the consent form may result in the denial of eligibility or termination of assisted housing benefits, or both. Denial of eligibility or termination of benefits is subject to the HA s grievance procedures and Section 8 informal hearing procedures. Sources of Information To Be Obtained State Wage Information Collection Agencies. (This consent is limited to wages and unemployment compensation I have received during period(s) within the last 5 years when I have received assisted housing benefits.) U.S. Social Security Administration (HUD only) (This consent is limited to the wage and self employment information and payments 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 is limited to unearned income [i.e., interest and dividends].) Information may also be obtained directly from: (a) current and former employers concerning salary and wages and (b) financial institutions concerning unearned income (i.e., interest and dividends). I understand that income information obtained from these sources will be used to verify information that I provide in determining eligibility for assisted housing programs and the level of benefits. Therefore, this consent form only authorizes release directly from employers and financial institutions of information regarding any period(s) within the last 5 years when I have received assisted housing benefits. Original is retained by the requesting organization. ref. Handbooks , , & form HUD-9886 (7/94)

12 Consent: I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form for the purpose of verifying my eligibility and level of benefits under HUD s assisted housing programs. I understand that HAs that receive income information under this consent form cannot use it to deny, reduce or terminate assistance without first independently verifying what the amount was, whether I actually had access to the funds and when the funds were received. In addition, I must be given an opportunity to contest those determinations. This consent form expires 15 months after signed. Signatures: Head of Household Social Security Number (if any) of Head of Household Other Family Member over age 18 Spouse Other Family Member over age 18 Other Family Member over age 18 Other Family Member over age 18 Other Family Member over age 18 Other Family Member over age 18 Privacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this information by the U.S. Housing Act of 1937 (42 U.S.C et. seq.), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and by the Fair Housing Act (42 U.S.C ). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants and participants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income and other information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your family will pay toward rent and utilities. Other Uses: HUD uses your family income and other information to assist in managing and monitoring HUD-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 regulatory investigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permitted or 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 members six years of age and older is mandatory, and not providing the Social Security Numbers will affect your eligibility. Failure to provide any of the requested information may result in a delay or rejection of your eligibility approval. 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 of information 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 Any person who knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $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, against the officer or employee of HUD, the HA or the owner responsible for the unauthorized disclosure or improper use. Original is retained by the requesting organization. ref. Handbooks , , & form HUD-9886 (7/94)

13 DECLARATION OF CITIZENSHIP (SECTION 214) STATUS Notice to applicants and tenants: In order to be eligible to receive the housing assistance sought, each applicant for, or recipient of, housing assistance must be lawfully within the U.S. Please read the Declaration statement carefully and sign and return to Northwest Georgia Housing Authority s office. Please feel free to consult with an immigration lawyer or other immigration expert of your choosing. Name of Head of Household (Please print) SS# of Head of Household I,, certify, under penalty of perjury (refer to #1 on back of form), that, to the best of my knowledge, I am lawfully within the United States because (please check the appropriate box): I am a citizen by birth, a naturalized citizen or a national of the United States; or I have eligible immigration status and I am 62 years of age or older. Attach evidence of proof of age (refer to #2 on back of form), or I have eligible immigration status as checked below (see reverse side of this form for explanations). Attach INS document(s) evidencing, eligible immigration status and signed verification consent form. Immigration status under şş101(a)(15) or 101(a)(201) of the Immigration and Nationality Act (INA) (refer to #3 on back of form), or Permanent residence under ş249 of INA (refer to #4 on back of form); or Refugee, asylum, or conditional entry status under şş207, 205 or 203 of the INA (refer to #5 on back of form), or Parole status under ş212(d)(5) of the INA (refer to #6 on back of form); or Threat to life or freedom under ş243(h) of INA (refer to #7 on back of form); or Amnesty under ş245 of INA (refer to #8 on back of form). Signature of Family Member { Check here if you are signing for minor child listed above and you are an adult residing in the unit who is responsible for that child. Housing Authority: Enter INS/SAVE Primary Verification #: (See reverse side for footnotes and instructions)

14 1. Warning: 18 U.S.C.1001 provides, among other things, that whoever knowingly and willfully makes or uses a document or writing containing any false, fictitious, or fraudulent statement or entry, in any matter within the jurisdiction of any department or agency of the United States, shall be fined not more that $100,000, imprisoned for not more than five years, or both. The following footnotes pertain to non-citizens who declare eligible immigration status in one of the following categories: 2. Eligible immigration status and 62 years of age or older. For non-citizens who are 62 years of age or older or who will be 62 years of age or older and receiving assistance under a Section 214 covered program on June 19, If you are eligible and elect to select this category, you must include a document providing evidence of proof of age. No further documentation of eligible immigration status is required. 3. Immigrant status under şş101(n)(15 or 202(a)(20) of INA. A non-citizen lawfully admitted for permanent residence, as defined by ş101(a)(20) of the Immigration and Nationality Act (INA), as an immigrant, as defined by ş101(a)(15) of the INA (8 U.S.C. 1101(a)(20) AND 1101(A)(15), respectively (immigrant status). This category includes a non-citizen admitted under şş210 or şş210a of the INA (8 U.S.C or 1161), (special agricultural worker status), who has been granted lawful temporary resident status. 4. Permanent residence under ş249 of INA. A non-citizen who entered the U.S. before January 1, 1972, or such later date as enacted by law, and has continuously maintained residence in the U.S. since then, and who is not ineligible for citizenship, but who is deemed to be lawfully admitted for permanent residence as a result of an exercise of discretion by the Attorney General under ş249 of INA (8 U.S.C. 1259) (amnesty granted under INA 249). 5. Refugee, asylum, or conditional entry status under şş207, 205 or 203 of INA. A non-citizen who is lawfully present in the U.S. pursuant to an admission under ş207 of the INA (8 U.S.C. 1157) (refugee status); pursuant to the granting of asylum (which has not been terminated) under ş208 of the INA (8 U.S.C. 1158) (asylum status); or as a result of being granted conditional entry under ş203(a)(7) of the INA (U.S.C. 1153(a)(7) before April 1, 1980, because of persecution or fear of persecution on account of race, religion, or political opinion or because of being uprooted by catastrophic national calamity (conditional entry status). 6. Parole status under ş212 (d)(5) of INA. A non-citizen who is lawfully present in the U.S. as a result of an exercise of discretion by the Attorney General for emergent reasons or reasons deemed strictly in the public interest under ş212 (d)(5) of INA (8 U.S.C. 1182(d)(5)) (parole status). 7. Threat to life or freedom under ş243(h) of INA. A non-citizen who is lawfully present in the U.S. as a result of the Attorney General s withholding deportation under ş243(h) of INA (8 U.S.C. 123(h) (Threat to life or freedom). 8. Amnesty under ş245a of INA. A non-citizen lawfully admitted for temporary or permanent residence under ş245a of INA (8 U.S.C. 1255a) (amnesty granted under INA 245A). Instructions to Housing Authority: Following verification of status claimed by persons declaring eligible immigration status (other than for non-citizens age 62 or older and receiving assistance on June 19, 1995), HA must enter INS/SAVE Verification Number and date that it was obtained. A HA signature is not required. Instructions To Family Member For Completing Form: On opposite page, print or type first name, middle initial(s), and last name. Place an X or in the appropriate boxes. Sign and date at bottom of page. Place an X or in the box below the signature if the signature is by the adult residing in the unit who is responsible for Child.

15 APPLICANT / RESIDENT CERTIFICATION I / We certify that the information* given to Northwest Georgia Housing Authority on household composition, income, net family assets, and allowances and deductions 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 termination of housing assistance and termination of tenancy. _ Head of Household Signature Spouse or other Adult Signature If you believe you have been discriminated against, you may call the Fair Housing and Equal Opportunity national toll-free hot line at (Within the Washington, D.C. Metropolitan area, call *After verification by this Housing Agency, the information will be submitted to the Department of Housing and Urban Development on Form HUD (Tenant Data Summary), a computergenerated facsimile of the form or on magnetic tape. See the Federal Privacy Act Statement for more information about its use LLG

16 ZERO INCOME VERIFICATION For the Month of Name: Account # Address: Phone # I, do hereby certify that I have zero income. I DO NOT receive money from any source, including relative and friends, any income or payments on my behalf on a regular basis. I understand it is my responsibility to report any change in my income to Northwest Georgia Housing Authority. WARNING: SECTION 1001 OF TITLE 18 OF THE UNITED STATES CODE MAKES IT A CRIMINAL OFFENSE TO WILLFULLY MAKE A FALSE STATEMENT OR MISREPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AS TO ANY MATTER WITHIN ITS JURISDICTION. Signature of Applicant/Resident Signature of Applicant/Resident NWGHA Representative Revised LLG

17 VERIFICATION OF CHILD SUPPORT To: Account # Case Name SS # Please list dependents below. I do hereby authorize Child Support Recovery to furnish the Housing Authority with the information requested. Applicant/Resident Signature Northwest Georgia Housing Authority is required to verify the income of all participants in the federally assisted housing programs operated by the Housing Authority. We ask your cooperation in supplying the information listed below. Housing Agency Representative Signature Phone # Do you (applicant/resident) receive child support? Yes. Please list amount $ Initials No. Resident/Applicant Signature Completed by: Name & Title: (Please Print) : Phone: Revised LLG

18 REQUEST FOR VERIFICATION OF EMPLOYMENT INCOME TO: Company Name: DATE: RE: Name Phone: Social Security Number Northwest Georgia is required by Federal Law to verify the total family income of all applicants and participants in the federally assisted housing programs operated by the Housing Authority. An authorization for release of information signed by the above-referenced individual is below. We ask your cooperation in furnishing the required information as follows: 1. of Employment: 2. Pay Rate: Hourly: Weekly: Salary: Bi-Weekly: Monthly: 3. Regular hours worked per week 4. If hours worked per week vary, please give an average number of hours worked per week. 5. Is this a Government Funded Program? Yes No I hereby authorize my employer to release the information requested directly to the Housing Authority. Employee Signature If you have any questions, please do not hesitate to call me. Your prompt attention to this matter will be appreciated. Telephone # Housing Agency Representative Employer Representative Telephone # Title NOTE: Please return this form via fax to the fax number listed below. Fax # Revised LLG

19 VERIFICATION OF TEMPORARY ASSISTANCE FOR NEEDY FAMILIES TO: Account # Department of Family and Children Services State of Georgia County of Floyd Case Name SS# Please list dependents below. I do hereby authorize the Department of Family and Children Services to furnish Northwest Georgia Housing Authority (NWGHA) with the information requested above. Applicant/Resident Signature Do you receive any assistance form the Department of Family and Children Services? Yes. Please list amount $ Initials No. Resident/Applicant Signature Northwest Georgia Housing Authority is required to verify the income of all applicants/residents in low-income housing. We ask your cooperation in supplying the requested information listed below. NWGHA Representative _ VERIFICATION: DFCS: Effective : Amount $ Do you have any information of any income from other sources for the person(s) listed, or anyone living at this address: Yes No If yes, amount per month $ from $ from Number of minors in family:_ Closed: (Please complete reason for termination if case is closed.) Reason for termination: REMARKS: DFACS to PHA: Completed by: Name & Title: Phone # (Please print) Revised LLG

20 NOTICE TO APPLICANTS CONCERNING PREFERENCES Northwest Georgia Housing Authority selects its applicants for housing on a first come, first served basis, and several preferences that include a local preference. There are four priorities, which are: 1) Local/working preference; 2) Being involuntarily displaced: 3) Living in substandard housing; and 4) Paying more than 50% of the monthly income for rent and utilities. These are further defined as follows: 1. An applicant is working and income does not exceed HUD s limit. 2. An applicant may be involuntarily displaced if the applicant has vacated or will have to vacate his or her housing unit as a result of a disaster, such as a fire or flood, that results in the un-inhabitability of the unit, displacement by a governmental body or agency or certain action by a housing owner that results in an applicant having to vacate his or her unit. An applicant also is involuntarily displaced if the applicant has vacated his or her housing unit as a result of actual or threatened physical violence directed against the applicant or applicant s family members by a spouse or other member of the applicant who lives in a housing unit with such an individual who engages in such violence. 3. An applicant may be living in substandard housing if the unit is dilapidated, without operable indoor plumbing, without a usable bathtub or shower, without a usable flush toilet inside the unit, without safe and adequate electrical service, without safe or adequate source of heat, without a kitchen or has been declared unfit for habitation. An applicant who is a homeless family may be considered as living in substandard housing. 4. Paying more than 50% of income for rent and utilities includes payments for rent or payments to amortize the purchase price of a manufactured home plus the cost of the housing authority s reasonable estimate of tenant-purchased utilities (except telephone and cable) and other housing services that are normally included in rent. If you feel that you may qualify for a preference, please advise this office and be prepared to provide verification. The Housing Authority is required to adequately verify any applicant s claim for any preferences. CERTIFICATION The undersigned applicant hereby certifies that he or she was informed of Northwest Georgia Housing Authority preferences and was given an opportunity to show that he/she may qualify for a preference. Applicant Signature Revised LLG

21 Notice to all Applicants / Residents Reasonable Accommodations for Applicants / Residents with Disabilities Northwest Georgia Housing Authority (NWGHA) is a public agency that provides low rent housing to eligible families, elderly families and single people. NWGHA is not permitted to discriminate against applicants on the basis of their race, religion, sex, national origin, or disability. In addition, NWGHA has a legal obligation to provide reasonable accommodations to applicants/residents if they or any family members have a disability. A reasonable accommodation is some modification or change NWGHA can make to its apartments or procedures that will assist an otherwise eligible applicant with a legally recognized disability to take advantage of NWGHA s programs. Examples of reasonable accommodations would include the following: Making alterations to a NWGHA unit so it could be used by a family member (resident) with a wheelchair; Installing strobe type flashing light smoke detectors in an apartment for a family with a hearing impaired member; Permitting a family to have a support animal necessary to assist a family member with a disability in a NWGHA family development where animals are not usually permitted; Making large type documents or a reader available to a vision-impaired applicant during the application process; Making a sign language interpreter available to a hearing impaired applicant during the interview; Permitting an outside agency to assist an applicant with a disability to meet the NWGHA s applicant screening criteria. An applicant family that has a member with a disability must still be able to meet essential obligations of tenancy they must be able to pay rent, to care for their apartment, to report required information to the Housing Authority, to avoid disturbing their neighbors, etc; however, there is no requirement that they be able to do these things without assistance. If you or a member of your family have a disability, you may request a reasonable accommodation at the application process or after admission. This is up to you. If you would prefer not to discuss your situation with the Housing Authority, that is your right. Applicant/Resident Signature NWGHA Representative Signature Revised LLG

22 SPECIAL UNIT REQUIREMENT(S) QUESTIONNAIRE This questionnaire is to be administered to every applicant for public housing at Northwest Georgia Housing Authority (NWGHA) and residents (during re-certification). It is used to determine whether an applicant/resident family needs special features in their housing unit. The need for special adaptations must be verified in order to assure that the limited number of units with special features go to families that actually need the features. We ask that every applicant sign the bottom of the form to indicate receipt of the form, whether or not any special features are requested. No one is required to disclose a disability. Applicant Name: File # Interview Conducted by: : 1. Will you, or any member of your family require any of the following: Yes No If yes, please check all that apply. A separate bedroom Unit for Vision-Impaired A barrier-free apartment Unit for Hearing-Impaired One-level unit Bedroom & Bath on 1 st floor Live in Aide Extra Bedroom Other 2. Do you or any family members need any features not mentioned? Yes No If yes, please indicate how NWGHA should accommodate your family: 3. Will you or any of your family members require a live-in aide to assist you? Yes No If yes, please explain: 4. If you checked any of the above listed categories of units, please explain exactly what you need to accommodate your situation: 5. What is the name of the family member needing the features identified above? 6. Whom should we contact to verify your need for a special apartment: Name: Address: Phone # Applicant/Resident Signature NWGHA Representative Signature Revised LLG