Tài liệu HAJC APPLICATION PROCEDURES pdf

HOUSING AUTHORITY OF JEFFERSON COUNTY (HAJC) Mailing Address: Post Office Box 2109  Physical Address: 5210 Kuhn Street Port Townsend, WA 98368 Phone (360) 379-2565  Fax (360) 379-2561 HAJC APPLICATION PROCEDURES 1) Applications will be accepted via mail or over the counter ONLY. Submit original application along with:  Declaration of citizenship form, enclosed, for each adult in the household. A copy of each person’s social security card, (over the age of six) must also accompany each application. Applications must be signed by each person over the age of 18. 2) Application is processed and you are placed on the waiting list. 3) A letter will be sent to applicant to inform them that placement on the waiting list has occurred. 4) Placement on the waiting list may be reviewed on our website at www.jeffersonhousing.org . Allow 4 weeks for this information to appear on the webpage. 5) When applicant’s name comes up on the waiting list, applicant will be notified by MAIL. 6) APPLICANT IS RESPONSIBLE TO NOTIFY HAJC IN WRITING OF ANY CHANGES OF ADDRESS, within 10 days. 7) If notification is returned from the post office due to insufficient address, applicant will be removed from the waiting list. No further notification will be sent. 8) If notification is returned from the post office due to “Moved, left no forwarding address” status, applicant will be removed from the waiting list. No further notification will be sent. 9) Section 8 waiting list only: Once every 6 months to 1 year, the Section 8 waiting list is updated. If applicant does not respond to the request for updated information (Purge) within the given time frame, applicant will be removed from the waiting list. HOUSING AUTHORITY OF JEFFERSON COUNTY (HAJC) 5210 Kuhn Street  Port Townsend, Washington 98368 Phone (360) 379-2565  FAX (360) 379-2561 Eligibility Pre-Application Form Housing Choice Voucher Program: Jefferson County Applicant Information Last Name First Name Middle Mailing Address City State Zip Street Address City State Zip Home Tel. ( ) Mess. Tel. ( ) Work Tel. ( ) Household Members: Start with head of household, then list spouse/co-head, then minors, then any other adults. Legal Name Last, First, Middle Initial Sex M/F Relationship to Head Social Security Number Date of Birth Month/date/year Place of Birth City/State 1 Head 2 3 4 5 6 7 Optional Information for Statistical Purposes Only (Please check all that apply): Head of Household:  African American/Black  Caucasian/White  Asian  Pacific Islander  Native American/Alaskan Native  Multi-Racial  Hispanic Spouse/Other Adult:  African American/Black  Caucasian/White  Asian  Pacific Islander  Native American/Alaskan Native  Multi-Racial  Hispanic Children:  African American/Black  Caucasian/White  Asian  Pacific Islander (mark all that apply)  Native American/Alaskan Native  Multi-Racial  Hispanic Are you a Veteran?  Yes  No Are you Homeless?  Yes  No 1. Have you or anyone in your household ever used any other name(s)?  Yes  No If yes, what name(s) and who used it? ____________________________________________ 2. Have you or anyone in your household ever used a social security number other than those listed?  Yes  No If yes, what number(s) and who used it? ___________________________________________ The following are types of income that must be reported: ¾ Wages, Tips, Salary ¾ TANF ¾ VA Benefits ¾ Social Security, SSI, SSDI ¾ Unemployment ¾ Pension or retirement ¾ Worker’s Compensation ¾ Child Support ¾ Per Capita payments ¾ Interest income from bank accounts, investments etc. ¾ Income from real estate ¾ Contributions from family members (this includes regular payments of bills, purchase of products such as diapers, food etc.) INCOME INFORMATION: Please list the source and amount of all current income received by all household members, including your children and yourself. Household Member Name Income Source Monthly Amount Hourly Wage # of Hours per week $ $ $ $ $ $ $ $ ATTENTION APPLICANT: You are responsible for maintaining current and accurate application information. You are required to notify the Housing Authority of Jefferson County in writing of any change in address; income and/or household composition (please use “Change of Circumstance” form available in the lobby). If we cannot contact you at the address listed on this application or an updated address, your name will be removed from the waiting list, and you will have to re-apply. Are you or any other members of your household disabled? Yes _____ No _____ If yes, which member(s) are disabled? __________________________________ __________________________________ __________________________________ __________________________________ Do you or any member of your family require any of the following accommodations or unit modifications? • Wheelchair accessible unit • Sensory impaired accessible unit • Ground floor unit (no stairs) • Other physical adaptations (grab bars etc.) • Service/Companion Animal • Copy mail to Case Manager • Large type documents • Live-in aide/caregiver • Payee (please list name) ___________________________ • Other _______________________________________________________ The Housing Authority of Jefferson County complies with the Fair Housing Act and provides reasonable accommodations and modifications to persons with disabilities. Special Assistance 1) Do you need this document translated into a language other than English? If yes, which language? _______________________ a) Kailangan nyo po ba ang ibang pananalita o linguwahe para isalin itong dokumentong ito maliban sa Ingles? Kung oo, ano po bang pananalita o linguwahe? ______________________________ b) ¿Necesita usted que este documento sea traducido a otro idioma diferente que en ingles? ¿Si es asi, que idioma? ________________________________ c) Bạn có cần tài liệu này ðuợc dịch qua ngôn ngữ nào khác ngoài tiếng Anh không? Nếu có, ngôn ngữ nào? _______________________ 2) Do you need help communicating with the Housing Authority of Jefferson County in a language other than English? If yes, which language? _____________________ a) Kailangan nyo po ba ang tulong para makausap ang Housing Authority of Jefferson County sa ibang pananalita o linguwahe maliban sa Ingles? Kung oo, ano po bang pananalita o inguwahe? ______________________ b) ¿ Necesita usted comunicarse con la autoridad de vivienda de Jefferson County en otra idioma que no sea el ingles? ¿Si es asi, que idioma? ________________________________ c) Bạn có cần thông dịch khi giao tiếp với Housing Authority of Jefferson County không? Nếu có, ngôn ngữ nào? _______________ 3) Do you need sign language assistance for your appointments with the Housing Authority of Jefferson County? Yes ________ No ________ If you want the Housing Authority of Jefferson County to speak with your case manager, friend or relative about your housing status, you must first complete and sign the following release. Remember to write in the name of the person that you are allowing us to speak with and sign the bottom of the release. RELEASE OF INFORMATION I, ______________________, give the Housing Authority of Jefferson County permission to CLIENT NAME (print) speak with _______________________________________________ regarding my housing application. (Name of Person or Organization) I voluntarily allow the above named parties to obtain and/or release information regarding my housing application. I understand that this information will not be forwarded to anyone other than the parties listed above, without my written permission. I understand that I can revoke this release at any time. This consent form expires 15 months after signing. _________________________________ _______________ _____________________ Applicant’s Signature Date of Birth Social Security Number It is the responsibility of all clients to provide accurate and complete information to HAJC. If you do not provide all required information or if you submit false information to HAJC you may be charged with federal fraud. (Title 18, Section 1001 of the U.S. Code) I CERTIFY THAT ALL INFORMATION I HAVE PROVIDED IS COMPLETE AND ACCURATE. I understand that any misrepresentation of information or failure to disclose information requested on this application may disqualify me from consideration for admission or participation, and may be grounds for eviction or termination of assistance. I understand that this is not a contract and does not bind either party. The information contained in this application is true, and complete to the best of my knowledge. I have no objection to inquiries being made for the purpose of verifying the statements made herein. _____________________________________ ______________ ______________________________________ ____________ Head Of Household Signature Date Co-Applicant Signature Date HOUSING AUTHORITY OF JEFFERSON COUNTY Mailing Address: Post Office Box 2109  Physical Address: 5210 Kuhn Street Port Townsend, WA 98368 Phone (360) 379-2565  Fax (360) 379-2561 Equal Housing Opportunity Barrier Free rev 03/07/01 f:\housing\forms\declr14.doc Declaration of 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 it to the Bremerton Housing Authority Office. Please feel free to consult with an immigration lawyer or other immigration expert of your choice. I, ____________________________________________ certify, under penalty of purjury 1 , 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, naturalized citizen or national of the United States; or [ ] I have eligible immigration status and I am 62 years of age or older. (Attach proof of age) 2 ; 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. [ ] Immigrant status under ¶¶ 1001(a)(15) or 101(a)(20) of the INA 3 ; or [ ] Permanent residence under ¶ 249 of INA 4 ; or [ ] Refugee, asylum, or conditional entry status under ¶¶ 207, 208 or 203 of the INA 5 ; or [ ] Parole status under ¶¶ 212(d)(f) of the INA 6 ; or [ ] Threat to life or freedom under ¶ 243(h) of the INA 7 ; or [ ] Amnesty under ¶ 245 of the INA 8 . ________________________________________ _____________________________ (Signature of Family Member) (Date) *Parent/Guardian must sign for family members under age 18 . DO NOT sign child’s name.* [ ] Check box if signature of adult residing in the unit who is responsible for child named on statement above. [See reverse side for footnotes and instructions] Equal Housing Opportunity Barrier Free rev 1/7/00 Instructions to Housing Authority: Following verification of status claimed by person declaring eligible immigration status (other than for noncitizens age 62 or older and receiving assistance on June 19, 1995), the HA must enter INS/SAVE Verification Number and date that it was obtained. An 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. 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 manner within the jurisdiction of any department or agency of the United States, shall be fined not more than $10,000 or imprisoned for not more than five years, or both. The following footnotes pertain to noncitizens who declare eligible immigration status in one of the following categories: 2 Eligible immigration status and 62 years of age or older. For noncitizens who are 62 years of age or older or who will be 62 years of age or older and receiving assistance under Section 214 covered program on June 19, 1995. 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 ¶¶ 101(a)(15) or 101(a)(20) of INA. A noncitizen lawfully admitted for permanent residence, as defined by ¶ 101(a)(20) of the Immigration and Nationality Act (INA), as an immigrant, as defined by ¶ 101(a)(15) of the INA (8 U.S.C. 1101(a)(20) and 1101(a)(15), respectively [immigrant status]. This category includes a noncitizen admitted under ¶¶ 210 or 210A of the INA (8 U.S.C. 1160 or 1161), [special agricultural worker status], who has been granted lawful temporary resident status. 4 Permanent residence under ¶ 249 of INA. A noncitizen 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 ¶ 249 of the INA (8 U.S.C. 1259) [amnesty granted under INA 249]. 5 Refugee, asylum, or conditional entry status under ¶¶ 207, 208 or 203 of INA. A noncitizen who is lawfully present in the U.S. pursuant to an admission under ¶ 207 of the INA (8 U.S.C. 1157) [refugee status]; pursuant to the granting of asylum (which has not been terminated” under ¶ 208 of the INA (8 U.S.C. 1158) [asylum status]; or as a result of being granted conditional entry under ¶ 203(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 ¶ 212(d)(5) of INA. A noncitizen 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 ¶ 212(d)(5) of the INA (8 U.S.C. 1182(d)(5)) [parole status]. 7 Threat to life or freedom under ¶ 243(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 ¶ 243(h) of the INA (8 U.S.C. 1253(h)) [threat to life or freedom]. 8 Amnesty under ¶ 245A of INA. A noncitizen lawfully admitted for temporary or permanent residence under ¶ 245A of the INA (8 U.S.C. 1255a) [amnesty granted under INA 245A] . Fax (360) 379-2561 HAJC APPLICATION PROCEDURES 1) Applications will be accepted via mail or over the counter ONLY. Submit original application along with:. age of six) must also accompany each application. Applications must be signed by each person over the age of 18. 2) Application is processed and you are