Housing Authority of Utah County 240 ECenterS treet,p rovo,u tah Fax

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Board Members AngieM ris,chair DaveT uckett,vice-chair Am y A lred S tevew hite BilL ee Applicant: Housing Authity of Utah County 240 ECenterS treet,p rovo,u tah84606-3162 Fax801 373-2270 Lynell

1 Board Members AngieM ris,chair DaveT uckett,vice-chair Am y A lred S tevew hite BilL ee Applicant: Housing Authity of Utah County 240 ECenterS treet,p rovo,u tah Fax Lynell Smith Executive Direct Hours: 7:30 am 5:30 pm Mon - Thursday Closed Friday Asyou areconsideringapplyingfthes ection8 HousingChoiceVoucherprogram,pleaseconsiderthe folow ing: APPLICATIOS CA BE FILLED OUT AD SUBMITTED OLIE AT: APPLICATIOS CA BE PRITED OLIE AT: APPLICATIOS CA BE PICKED UP AT: 240 E CETER STREET I PROVO, UT APPLICATIOS CA BE MAILED TO OU B CALLIG: ET ou m ustfilintheprelim inary applicationcom pletely.anyoneoverageof18 inthehousehold m ustsignalfm saccom panyingthisapplication. 2. Ifthereare2 m echildreninthehousehold you m ay requestat rue thapplicationas w elass ection8 ifyou areinterested inlivinginoneoftheunitsthatthehousingauthity ow nsandm anages. 3. W edonotassistinp rovo.ifyou currently liveinp rovoand intend tocontinuelivingthere, pleasecontactp rovocity HousingAuthity located at650 W 100 inp rovo,u T 84601;phone: P leasebeadvisedthatouragency hastherightand w ilperfm abackground checkasrequired feligibility. Fam iliesand individualsthatlegaly resideintheu nited S tatesand falw ithinthefolow inglow -incom e guidelinesareeligiblefassistance. # I FAMIL MOTHL ICOME AUAL ICOME 1 2,179 26, ,491 29, ,804 33, ,112 37, ,362 40, ,612 43, ,862 46, ,112 49,344 Families and individuals with income levels in excess of the income as established by HUD (very low income limit listed above) do not qualify f Section 8 Voucher Assistance.

2 PRELIMIAR APPLICATIO PLEASE COMPLETE THIS FORM AD RETUR TO: Housing Authity of Utah County 240 East Center Street Provo, UT Received/ Revised Office Use Only Unit Size Preference ame: Legal address if different from mailing address Address: City, State, Zip Code: ote: If your legal mailing address changes, you must notify this office to maintain your waiting list status. Evidence of legal address claimed at time of application must accompany this fm when returned. Acceptable evidence includes copy of driver's license other official document listing head of household, spouse co-head at claimed legal address. Preliminary Applications returned without evidence of legal address cannot be accepted. Part 1: Head of Household Social Security umber Date of Birth Sex Home Telephone Other Telephone Other Telephone Type Address Female Wk Part 2: Household Infmation Male Other Specify: I would like to receive crespondence via . Do you qualify f a reasonable accommodation due to a disability? Ethnicity (Check One Box) Race (Check All That Apply) Hispanic/Latino ot Hispanic/Latino List infmation f adults first, then children under age 18. Use "F" "M" to indicate sex. If a household member qualifies f a reasonable accommodation due to a disability select "", if not, select "." List relationship of each person to the Head of Household. Attach additional sheet if family has me than ten members. OR es o White Black/African American American Indian/ Alaska ative Asian ative Hawaiian/Other Pacific Islander Racial and ethnic data f statistical purposes only. First ame MI Last ame Social Security # Date of Birth Sex Disabled Relationship Please Continue to Part 3 HAPP Software, Inc. 5/31/2018 Page 1

3 PRELIMIAR APPLICATIO Part 3: Family Income and Assets List total gross income (befe taxes) and payments received by each family member age 18 and older f wages, military pay, pensions, social security, SSI, welfare, child suppt, unemployment, business, profession any other source. Include payments made to family members 18 older on behalf of other family members under age 18. First ame Gross Income How Often Weekly Every 2 Weeks Monthly early Weekly Every 2 Weeks Monthly early Weekly Every 2 Weeks Monthly early Weekly Every 2 Weeks Monthly early Weekly Every 2 Weeks Monthly early List total cash value and total income received f assets owned by all family members. If Income is from Wages List Address of Employer Type of Asset Cash Value of Asset Income Received from Asset Checking Accounts Savings Accounts Stocks, Bonds, CDs, Investment Real Estate Other Part 4: Eligibility and Preferences our response to the following statements will help determine your eligibility f rental assistance and if you are entitled to a preference when placed on the program's waiting list. Select each item that applies to your current status. Are you a victim of domestic violence by a member of your household in the last 180 days? Do you currently have min children in your household? Are you age 62 older? Part 5: U.S. Citizenship otification and Certification Housing may be contingent upon the submission and verification of evidence of citizenship eligible immigration status pri to the time housing is made available. Based on the evidence submitted at that time, assistance may be prated, denied terminated following appeals and infmal hearing processes. I certify that the infmation on this fm is true and complete to the best of my knowledge and belief. I understand that I can be fined up to 10,000, imprisoned up to five years if I furnish false incomplete infmation. x Date Privacy Act otice: F your protection, the data collected on this fm will only be released in accdance with the Privacy Act of HAPP Software, Inc. 5/31/2018 Page 2

4 DECLARATIO OF CITIZESHIP May 31, 2018 PLEASE COMPLETE THIS FORM AD RETUR TO: ame: Housing Authity of Utah County 240 East Center Street Provo, UT Tenant ID Address: City, State, Zip Code: Part 1: Applies to All Family Members Each person who will benefit under the Section 8 Rental Assistance Program must either be a citizen national of the United States, be a noncitizen who has eligible immigration status that qualifies them f rental assistance as determined by the U.S. Department of Housing and Urban Development and the U.S. Immigration and aturalization Service. One box on this fm must be checked f each family member indicating status as a citizen a national of the United States, a noncitizen with eligible immigration status. Family members residing in the unit to be assisted that do not claim to be a citizen national of the United States, do not claim to be a noncitizen with eligible immigration status should not check any box. All adults must sign where indicated. F each child who is not 18 years of age, the fm must be signed by an adult member of the family residing in the dwelling unit who is responsible f the child. Use blank lines to add family members who are not listed. First ame Last ame Age I am a citizen national of the U.S. I am a noncitizen with eligible immigration status. Signature of Adult Listed to the left, Signature of Guardian f Mins. Warning - Title 18 US Code Section 1001 states that a person is guilty of a felony f knowingly and willingly making a false fraudulent statement to any department agency of the United States. If this fm contains false incomplete infmation, you may be required to repay all overpaid rental assistance you received; fined up to 10,000, imprisoned f up to 5 years; and/ prohibited from receiving future assistance. OTE: Family members who have checked a box indicating that they are a noncitizen with eligible immigration status must complete Part 2 of this fm. HAPP Software, Inc. 5/31/2018 Page 1

5 Part 2: Applies to oncitizen Family Members Only All family members who have claimed eligible immigration status on Part 1 of this fm must provide this office with an iginal of one of the following documents: (1) Fm I-551, Alien Registration Receipt Card (2) Fm I-94, Arrival-Departure Recd with appropriate annotations documents (3) Fm I-688, Tempary Resident Card (4) Fm I-688B, Employment Authization Card (5) A receipt issued by the IS indicating that an application f issuance of a replacement document in one of the abovelisted categies has been made and the applicant s entitlement to the document has been verified. Please call at to arrange f delivery and copying of iginal documents. Do not mail iginal documents to this office. If documents are not presented and verified, your family s rental assistance may be reduced, denied, terminated as provided in regulations promulgated by the U.S. Department of Housing and Urban Development, pending available appeals processes. 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 fm and that members of my household that have not checked either box on Part 1 of this fm do not claim to be citizens nationals of the United States, noncitizens with eligible immigration status. Signature Date Consent to Verify Eligible Immigration Status Each family member required to complete Part 2 of this fm must sign below granting consent to verify eligible immigration status. F each child who is not 18 years of age, the fm must be signed by an adult member of the family residing in the dwelling unit who is responsible f the child. First ame Last ame Age Signature of Adult Listed to the left, Signature of Guardian f Mins. Office Use Only IS VERIF. # Evidence supplied with this fm may be released by the Housing Agency, without responsibility f its further use transmission, to the Immigration and aturalization Service f purposes of verification of the immigration status of the individual to the U.S. Department of Housing and Urban Development, as required. The U.S. Department of Housing and Urban Development is not responsible f the further use transmission of the evidence other infmation. HAPP Software, Inc. 5/31/2018 Page 2

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

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 $1,200.00 towards their rental deposit