LIPH-PUBLIC HOUSING Interim Request Notification

General Information

Reason\Type of Interim:

Attached is an Interim Packet that MUST include the following in order to process: Packet has to be completely filled out by the Head of household and all adult Household members.

Decrease Attached all document or loss income

a) If no longer employed, a letter from previous employer b) If you are no longer receiving benefits from state or federal agency, the letter of termination is needed c) Amount of decrease $____________________________ per month

Increase Attached all documentation of increase of income: a) If you received an increase of wages; a letter from your employer with that amount must be provided. b) If you are receiving benefits from a state or federal agency; a letter of acceptance of that assistance must be

provided. c) Amount of increase $_____________________________ per month

Change of Household Composition a) If you are removing a household member, you must provide a bill or lease with the individuals address. The

household member must also notarize the statement of removal form.

b) If you are interested in adding a household member because of a birth, adoption or legal custody you must first seek the permission of your landlord in writing and present that to HANH. No one has permission to move in to the unit without approval of a HANH Representative.

c) Name of person being added\ or removed.________________________________________________

The Following Documentation must be provided: Birth Certificate Social Security Card Child Custody Documentation Adoption Documentation

Note the Following: 1. All incomplete Interim Request Packets will be returned to you unprocessed. 2. You are allowed only Three (3) Interim Request per Year 3. You are still responsible for your current portion of your rent Until you have received a rent change notice from a

HANH representative 4. HANH has 30 days in which to process your interim request. 5. Interim decreases in rent are effective the month following the receipt of the interim packet 6. Interim increases in rent are effective, on the 1st of the month following the 30 days notice to the family 7. If an increase in income is not reported within 30 days, you will be retroactively charged to the date it would have

been effective if the information had been provided on a timely basis.

Thank you for your continued cooperation with the Public Housing Program.

Public Housing Staff

Head Of Household Name: Social Security:

Address:

Phone Number:

I understand, that to the best of my knowledge and belief, That the information provided is true, correct, complete, and made in good faith.

I understand that my interim recertification will not go into effect until the Housing Authority of the City of New Haven has received all of the necessary Documents.

I understand that I’m still responsible for my current rent portion until I have received a rent change notice from a HANH Representative.

Head of Household’s Signature Date:

Received by: __________ Date Stamp:

HANH Representative

NOTIFICACION INTERINO DE CAMBIOS PARA VIVIENDA PÚBLICA

Información General Jefe de Hogar: Seguro Social:

Dirección:

Número de Contacto:

Razón \ Tipo de Cambio:

Aumento: Aumento en ingresos en la cantidad de $___________ por mes.

(Ganancias totales antes de impuestos)

a. Si usted recibió un aumento de salarios; Una letra de su patrón con cantidad

b. Si as comenzado a recibir ventajas del estado o de la agencia federal; una letra de la aceptación de

esa ayuda es requerida

Disminución: Disminución en ingresos en la cantidad de $________ por mes. (Ganancias totales antes de impuestos)

a. Si no está empleado letra del patrón anterior es requerida b. Si no está colectando mas beneficio del estado o de una agencia federal la letra de terminación de la ayuda e

requerida, Cambio de Composición Familiar:

Añadiendo a un nuevo familiar: Proveer los siguientes documentos:

Certificado de Nacimiento Tarjeta de Seguro Social Papeleo de Custodia Papeleo de Adopción Certificado de Matrimonio Carta de Notificación y aprobación de su propietario Nombre del nuevo familiar:

Eliminado a un familiar: Proveer los siguientes documentos:

Factura de alguna compañía de utilidad con nueva dirección y/o Contrato de arrendamiento con nueva dirección y/o Reciente Talonario de Trabajo con nueve dirección y/o Notificación al DMV de nueve dirección Este miembro familiar que va a ser eliminado debe firmarnos una carta deseando ser eliminado la cual tiene

que ser notariada. Nombre del miembro familiar el cual será eliminado:

Observe por Favor el siguiente: 1. Todos los paquetes Interino incompletos le serán vueltos sin procesar 2. Solo Tres (3) paquetes Interino por ano 3. Usted es todavía responsable de su porción actual de su alquiler hasta que usted haya recibido un aviso de un HANH representativo 4. HANH tiene 30 días para procesar su Notificación Interino

Certifico que, al mejor de mi conocimiento y creencia, sobre esta declaración personal es verdad, correcto, completo, y hecho de buena fe.

Entiendo que esta notificación interino de cambio no se dará por efectivo Hasta tanto que el Departamento de Vivienda no reciba los documentos Necesarios para procesarlo.

Entiendo que soy responsable por la porción de renta que tengo hasta no recibir Una carta de los cambios hecho por un representante de la Vivienda,

Firma de Jefe de Hogar_____________________ Fecha: ________________________

Revisado por: ______ Fecha Sellado:_____________________

HOUSING AUTHORITY OF THE CITY OF NEW HAVEN (HANH)LOW INCOME PUBLIC HOUSINGMTW RE-EXAMINATION FORM

1. Name of head of household:

2. Name of adult co-head of household:,

3. Address, Street, Apt. # and Zip

4. Contact Numbers: Home:

Work:

Cell:

Other:

5. Drivers License or State ID # of head of household;

Automobile; Year: Make: Model: License:

6. Drivers License or State ID # of co- head of household:.Automobile: Year: Make: Model: License:

For Statistical Purposes OnlyRace of Head: C3 Caucasian/White G African American/Black CJ Asian or Pacific Islander

d Native American/ Alaskan Native d Other-

Ethnicity of Head: CJ Hispanic/Latino CJ Non-Hispanic/Non-Latino

FAMILY INFORMATION

7. List all persons who will live in the unit, including foster children, & live-in aides (for the care of a familymember). Each box must be completed for each member. No one except those listed on this form may live inthe unit.

H

2

3

4

5

•7

First Name & LastName if different fromHead's

Date ofBirth

Sex SocialSecurityNumber

Relationto

Head

Head

DisabledPerson?

Birthplace:Country

Full-timeStudent?

HOUSING AUTHORITY OF THE CITY OF NEW HAVEN (HANH)LOW INCOME PUBLIC HOUSINGMTW RE-EXAMINATION FORM

1. Nombre del jefe de hogar:

2. Nombre del co-jefe de hogar.

3. Direction ciudad, estado y codigo postal.

4. Numeros de telefonos: Hogar:

Trabajo:.

Celular:

Otro:

5. Numero de licencia de conducir del jefe de hogar:

Automovil: Aho: Marca: Modelo: Placas:

6. Numero de licencia de conducir del co-jefe de hogar:Automovil: Ano: Marca: Modelo: Placas:

Solamente Para Propositos EstadisticosBlanco/Caucasico tt Americano Africano/NegroRaza del:

AsiaticoJefe de Hogar CJ Americano Nativo / Natural de Alaska

Islefto Pacifico o

dOtro:

£tnica del jefe de Hogar a Hispano/Latino CJ No-Hispano/No-Latino

INFORMACION FAMILIAREnumere a todas las personas que vivan en la unidad, incluyendo ninos foster, Ayudantes (para el cuidadode un miembro de la familia). Cada espacio debe ser contestado para cada miembro de la familia. Nadiemas excepto los enumerados en esta forma pueden vivir en la unidad.

H

2

3

4

5

6

Primer Y Ultimo Nombre,(De Ser Dlferente Del Jefe DeHogar)

Fecha deNaclmiento

Sexo Numero deSeguro Social

Relacidnal jefe da

hogar

Jefe

Personancapacitada?

Lugar denacimiento:(Pafs,Estado)

^Estudlantede tiempocomplete?

FAMILY INCOME INFORMATION8. List the source and amount of all income expected for the coming 12 months for all family

members age 18 years of age or older, including yourself.

See income source examples below:

Wages from employment - Self-Employment Income - Social Security/Supplemental SecurityIncome/Social Security Disability Income - Welfare - Temporary Assistance to Aid Families(TANF) or General Assistance (SAGA)

Unemployment - Pension - Child Support - Other Non-Wage Source

Family Member Name

Head Of Household

IncomeSource

i

Amount $ Frequency -Per1

(G Hourly G Weekly G Bi-weeklyGSemi-monthly GMonthly

O Hourly G Weekly O Bi-weeklyGSemi-monthly GMonthly

G Hourly G Weekly D Bi-weeklynSemi-monthly GMonthly

G Hourly D Weekly (U Bi-weeklynSemi-monthly OMonthly

G Hourly G Weekly (G Bi-weeklyGSemi-monthly (GMonthly

9. Do you have a checking or savings account or own any Certificates of Deposit, stocks, bonds,etc? G Yes G No If yes, describe the type of asset(s) please:

What is the market value of all assets?10. Do you own any real estate? G Yes G No if yes, what is the address?

11. Have you sold any real estate in the past two years? G Yes G No If yes, what was theaddress? _

! Once all income are known and verified, convert income to an annual figure by multiplying:Hourly wages by the number of hours worked per year ( 2,080 for fulltime employment with 40 hours a week and noovertime:Weekly wages by 52:Semi-monthly wages ( paid twice each month) by 24; andBi-weekly wages ( paid every ether week by) by 26)

INFORMACION DE INGRESOS DE LA FAMILIA

Enumere la fuente y la cantidad de todos los ingresos esperado para los proximos12 meses para los miembros del hogar que vienen en la unidad y que tengan 18anos de la edad o de adelante, incluyendose.

Vease los ejemplos abajo de fuentes diferentes de ingresos:Ingresos por empleo - Ingresos por empleo de uno mismo - Todo Tipo de Seguro Social -Ingresospor ayuda estatal - Ayuda Temporal De Ayudar A Las Familias (TANF) - AsistenciaGeneral (SAGA) - Desempleo - Pension - Pension Alimenticia - Otras fuente delSalario

Nombre de losMiembros de Familia

Jcfe de Hogar

Fuente deIngresos

i

Cantidad $ Frecuencia-Per2

! I Por hora". Mensual

;Por horai I Mensual

1 Por horai _ ! Mensual

, ". Por hora1 ; Mensual

:_!Por horaD Mensual

nSemanal i.lBi-SemanaliJBi-Mensual

L^Semanal Bi-Semanal; JBi-Mensual

ilSemanal ',.. Bi-SemanalMBi-Mensual

CSemanal i , Bi-SemanalLiBi-Mensual

L'Semanal ! : Bi-SemanalGBi-Mensual

9. ^Tiene usted cuentas corrientes, o cuentas de ahorros o pose algun Certificado deDeposito, acciones, escrituras, etc.? l.lSiDe ser Si, describa el tipo de activo(s):Cual es el valor comercial de los activos?

!No

10. i,Posee Usted cualquier propiedad inmobiliaria {bienes raices)?De ser Si, favor de indicar la direccion?

11.

si ! ;NO

<i,Ha dispuesto usted o algun miembro de la familia de alguna clase deactivos o bienes raices en los ultimos dos anos por menos del precio delmercado? '.'Si nNoDe ser Si favor de indicar la direccion?

: Once all Income are known and verified, convert income to an annual figure by multiplying:Hourly wages by the number of hours worked per year ( 2,080 for fulltime employment with 40 hours a week and noovertime:Weekly wages by 52:Semi-monthly wages ( paid twice each month) by 24; and3t-weekly wages ( paid every other week by) by 26)

FOR FAMILIES WITH EXCEPTIONAL EXPENSES OF $2,000 OR MORE ANNUALLY

(PLEASE PROVIDE RECEIPTS AT TIME OF INTERVIEW)

12. Is the head of household or spouse age 62 or older or a person with a disability? GYes GNo

If yes, please answer the following questions. If no, please skip down to question # 16.

13. Does your household have any medical expenses (include insurance, Medicare deduction, doctor visits,hospital, clinic costs, medicine, therapy, supplies, medical transportation, etc.)? D Yes G No

If yes, please describe the type of expense (not your medical condition) and the non-reimbursedamount you spend per month on all medical expenses:

Type of expense:

Monthly medical expense:$

Name, address & phone # of someone who can verify the expense:

14. Do you have any expenses on behalf of a household member with disabilities so an adult in the familycan work? H Yes D No

If yes, describe the expense and monthly amount:Name, address & phone # of someone who can verify the expense:

15. Do you have childcare expenses for children under age 13 so an adult in the family can work, go toschool or attend job training? n Yes d No

If yes, name, address and phone # of childcare provider:

Monthly unreimbursed child care cost: $ _______

16. Is any member of the household 18 or older other than head and spouse a full time student n Yes CJ No

If yes, name of the family member and the name, address and telephone number of someone who canverify this information:

17. Is the head of household or spouse a person with a disability? CJYes GNo

If yes, name of the family member and the name, address and telephone number of someone who canverify this information:

I/We certify that the statements on this application are true to the best of my/our knowledge and belief and understand that theywill be verified. I/We authorize the release of information to the HANH by my/our employer(s), the Department of Publicassistance, the Social Security Administration, and/or other business or government agencies. I/We understand that any falsestatement made on this application will cause me/us to be disqualified for admission.

Head Signature Date

Co-aoplicant Signature Date

Sect. 1001 of Title 18 of (tie United Slates Code makes it a criminal offense to knowingly make false statements or misrepresent to any Department or Agency of;he United Stales lo any matter within its jurisdiction and has established penalty of fines up to $100. TOO and/or imprisonment not to exceed 5 years.

PARA FAMILtAS QUE TENGAS CASTOS EXCPCIONALES DE $2,000 OR MAS ANUALMENTE

(Favor De Proveer Recibos Al Tiempo De Entrevista)

12. Ese! jefe del hogardeedad 62 anos o el esposo(a) o habra algim familiar incapacitado? OSi

De ser Si, Favor De contester las siguientes preguntas. Der ser NO, favor de contester las preguntas desde el #16.

13. Tiene la familia algunos gastos medicos ( que incluyen, seguros medicos, deducciones del programa de

Medicare, visitas a doctores, hospitals, clinicas, medicinas, terepias, asrticulos, transportacion medica)? d Si

LlNO

De ser Si, favor describimos el tipo de gasto ( no su condicion medica) Y !a cantidad que queda sin serreembolsado que usted gasta mensulamente en todos sus gastos medicos:Tipo de Gasto: _

Gasto Medicos mensuales:$ _

Nombre, direccion y, numero tetefonico de alguna persona que pueda venficar estos gastos: _

14. Tiene algun gasto para cuidado de algun miembro incapacitado de la familia para que un adulto pueda trabajar

3 Si O No

De ser Si, Favor de describer el gasto mensual y la cantidad:Nombre, direccion y, numero telefonico de alguna persona que pueda venficar estos gastos:

15. Tiene la familia gastos para el cuidado de ninos menores de 13 anos para que un adulto de la familia peuda

trabajer, ir a la escuela o atender a alsun entrenamiento? O Si D No

De ser Si, Nombre, direccion, y numero telefonico del proveedor del cuidado del nino:

Cantidad de gasto mensual que no es reembolsado: $.

16. Hay algun miembro de la familia mayor de 18 anos; aparte de jefe de hpgar o esposo que es un estudiante de tiempocompleto n Si n NoDe ser Si, favor de proveemos el Nombre, direccion, y numero telefonico de alguna person que pueda venficaresta informacion:

17. Tiene el jefe de hogar o esposo(a) una condicion de incapacidad? HSi nNoDe ser Si, Favor de proveernos el Nombre, direccion, y numero telefonico de alguna persona que puedaverificar esta informacion:

Yo'.nostros certificamos que las deciaraciones hechas en esta soltcitud son vendicas, at mapr de mi\nuestro conocimienlo y de mislnuestracreencias y se enliende que seran comprobados. YcAnosotros autorizamos el lanzamiento de la informacion a HANH a traves de mi\opatrono(s), el Departamento de Asistencia Publica, la administration de seguro social, y\ otras agencias de negocios o agenaagubern amen tales. Yo\s entendemos que cualquier declaraclon falsa hecha en esta solicitud me\nos descalificar para la admission.

Jefe De Hogar Fecha

Co-Jefe De Hogar Fecha

.Sect 1001 of Title 18 of tne United States Code makes it a criminal offense to knowingly make false statements or misrepresent to any Department or Agency ofjhe United States to any matter within its jurisdiction and has established penalty of fines up to $100,000 and/or imprisonment not to exceed 5 years.

Authorization for the Release of Information/Privacy Act Noticeto the U.S. Department of Housing and Urban Development (HUD)and the Housing Agency/Authority (HA)

U.S. Department of Housingand Urban DevelopmentOffice 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)i Full address, name of contact person, and date)

Authority: Section 904 of the Stewart B. McKinney Homeless

.Assistance Amendments Act of I')88, as amended by Section 903

uf the Housing and Community Development Act of 1(>92 andSection 3003 of the Omnibus Budget Reconciliation Act of 1993.This law is found at 42 U.S.C. 3544.

['his law requires that you sign a consent form authorizing: ( 1 )IIUD and the Housing Agency/Authority (HA) to request verifi-cation of salary and wages from current or previous employers; (2)HUD and the HA to request wage and unemployment compensa-

tion claim information from the state agency responsible forkeeping that information; (3) HUD to request certain tax return

information from the U.S. Social Security Administration and theU.S. Internal RevenueService. The law also requires independent

verification of income information. Therefore, HUD or the HAmay 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 thesources I is ted on the form. HUD and [he HA need this in formationlo 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 computermatching programs with these sources in order to verify your

eligibility and level of benefits.

Usesoflnformation to be Obtained: HUD is required to protect

the income information it obtains in accordance with the PrivacyAct 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 HAsfor the purpose ofdetermining housing assistance. The HA is alsorequired to protect the income information it obtains in accordancewith any applicable State privacy law. HUD and HA employeesmay be subject to penalties for unauthorized disclosures or im-proper 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 yourhousehold who is 1 8 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 I 8 vears ot'aue.

Persons who apply for or receive assistance under the following

programs are required to sign this consent form:

i'HA-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 consentform may result in the denial of eligibility or termination ofassisted housing benefits, or both. Denial of eligibility or termi-nation of benefits is subject to the HA's grievance procedures andSection 8 informal hearing procedures.

Sources of Information To Be Obtained

State Wage Information Collection Agencies. (This consent islimited to wages and unemployment compensation I have re-ceived during period(s) within the last 5 years when I havereceived assisted housing benefits.)

U.S. Social Security Administration (HUD only) (This consent islimited to the wage and self employment information and pay-ments 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 islimited to unearned income [i.e., interest and dividends).)

Information may also be obtained directly from: (a) current andformer employers concerning salary and wages and lb) financialinstitutions concerning unearned income (i.e., interest and divi-dends). I understand that income information obtained from thesesources will be used to verity information that I provide indetermining eligibility for assisted housing programs and the levelof benefits. Therefore, this consent form only authorizes releasedirectly from employers and financial institutions of informationregarding any period(s) within the last 5 years when I havereceived assisted housing benefits.

Original is retained Dy the requesting organization. ret. HandbooKs M20.7, 7420 8, & 7465 1 form HUD-9886 (7/94)

Consent: I consent to allow HL'D or the HA to request and obtain income information from the sources listed on this form forthe purpose of verifying my eligibility and level of benefits under HI .D's assisted housing programs. I understand that H As that

receive income information under this consent form cannot use it to deny, reduce or terminate assistance without firstindependently verifying what the amount was, whether 1 actually had access to the funds and when the funds were received. Inaddition, I must be given an opportunity to contest those determinations.

This consent form expires 15 months alter signed.

Signatures:

Head of Household

l Security Number (if any) of Head of Household Other Family MomOer over age 18

Ither Family Member over age (8

;tier F;imiiy Memoer over age 18 Other Family Member over age 18

Other F;iriily 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 informationby the U.S. Housing Act o f ! 937 (42 U.S.C. 1437 et. seq.). Title VI of the Civil Rights Act of 1964(42 U.S.C. 2000d). and by the FairHousing Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 {42 U.S.C. 3543) requires applicants andparticipants 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 monitoring11 UD-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 permittedor 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. (Jiving [he Social Security Numbers of all household memberssix 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 (o penalties for unauthorized disclosures or improper uses ofinformation collected based on the consent form.

!J^e of the information collected based on the form HUD 9886 is restricted to the purposes cited on the form HUD 9886. Any person who knowingly or willfullymuuesls, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not morethan $5.000.

Any applicant or participant affected bv negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, against.'.-.a officer or employee ot HUD, the HA or the owner responsible for the unauthorized disclosure or improper use.

Tnginal is retained by the requesting organization. ref. Handbooks 7420.7, 7420 3, 4 7465.1 ;orm HUD-9886 (7,94)

Autorizacion para divulgar informacion/Aviso sobre la Ley de Confidenciatidadenviado al Departamento de Vivienda y Desarrollo Urbane (HUD) de los EE.UU.y a la Oficma/Autondad de Vivienda (HA)

Departamento de Vivienday Desarrollo Urbano de los EE.UU.Oficina de Vivienda Publica y paraComumdades Indigenas

Oficina de Vivienda Publica (PHAI que solicita la divulgacion de informacion.(Tache la casilla si no corresponded(Escnba la direccion completa. el nombre del representanle y la fecha )

Oficina de Vivienda para Comumdades Indigenas (IHA) quesolicita la divulgacion de informacion. (Tache la casilla si nocorresponds.) (Escnba la direccion completa. el nombredel representante y la (echa.)

Autoridad I.a Seccion W4 de In Ley Stewart R McKmnev de rnmiendas a la

Asisii'ncia para las I'ersonas sin llogar de 1988. en su lorma enmendada por la

Section *>01 Jo la ( ev de Vivienda v Desarrollo Comurmano de 1992 y la

Section HUH <le la Ley General de Cnncihacion del i'resupuesto de 1993 Lsta

lev \ encuemra en la Section 3544 del Titulo 42 del Codigo de los I-P. ( j l !

Dieha lev I/MIJC que Listed firme un Ibrmulano de consentimiento en virtud del

aial autoriAi ( I ) al Departamento de Vivienda v nesarrollo Urhano (Department

oi l lousing and Urban Dtvdopmcnt. en adelanle HL'D) v .1 la Oficma/Autondad

Je Vivienda (Housing Agency/Authority, en adeluntc HA) para solicitor

vcnlicacioncs de los .sueldos v salanos deveneadns de i-mpkoddres nctuales o

antenores, (2) al IIUD v a la HA para solicnar information sobre rcclamacioncs

de p;igo de salanos o mdemm/acion por desempleo a la entidad esmial

L'tiCiirsada de mantencr dicha mfmmacion, y ( * ) al lil.'D para solicitor eiena

miormacion itibrc la declaration de renta ,1 la Admirmtracion de Segundad

Social (Social Secuntv) v al Servicio de Rentas Intemas dc los KK UU iIRS) la

!c'v exige ademas una verification independiente de la information sobre

mgrcsos f*«r lo tanto. et HUD o !a HA puede solicitar inlormation ,t

insiitLiciono^i t'mancicras para venl'icar su idoneidad y el monto de los benefictos.

I inalidad; Al I'lrmareste tbrmulario dc consentimiento. usted auioriza al HUD v

,1 la HA mencionada para solicitor ijiformatiOn sobre sus ingresos a las tucntcs

tiiadas en el tbrmulano. Am bos orgamsmos necesitan esa inlbrmactwn para

vtrificar su ingreso familiar con el fin de ttrciorarse dt: que usted reiine las

condiciones para rccibir nenetlcios de asisicncia para conseeuir vivienda y que

jsos beneticios se fijcn en el monto correcto l.mto el HDD como la HA pueiien

panicipar en programas electronicos de concordance con estas tuentes para

venlicar su idoneidad y el monto de IDS beneticios

[•"ormas de empleo de la inTormatiOn obtcnida: Se cxige que el HUD protein

!;i intbrmacion ohtenida sobre inuresos. Je contbritiidad con la Ley de

Conlidencialidad de 1974. Seccion 552a del I'nulo 5 del Cudigo de los tfi UIJ

I-'I HUD puede dtvuli;;ir informacion (distinta de la correspondents A

Jc-clarLicHines de rental para cienas tljtses de u«> ordmjrto, por f lemplo. a oiros

orgiinismos gubernamentales con fines de .iphcacion de la ley, a orgamsmos del

gohiemo federal con fines de determmacion de la idoneidad para el empleo. y a

las HA con el ob|eio de determmar el monto de la asistencia para con.seguir

vivienda. I'arnbien se exige due !a HA proteja la informacion sot>rc ingresos que

uhtenya, de con form id ;id con cualijiner ley t'stntal de confidenciahdad aplitable

il caso Los empleados del HUD y de la HA pueden estar sujetos a sanciones por

Jmilgacion no autonzada o por uso impropio de la intormacion sobre mgresos

optcnida con el Ibrmulano de consentimiento. Los propietarios particulars nopueden solifitar ni recibir informacion aulori/ada pur este formulario.

()uien debe flrmar el formulario de consentimiento: Cada familiar resiiienie

on la pnipiedad mayor de 18 aflos debe llrmar el formulario de consentimiento

I •; nronso "btcncr la tlnna de nuevos Jdultos que ingrcscn a la rcsidencia o dc

ILiienes cumplan 18 anos.

Se exige que los sohcitantes o receptores de asistencia con arreglo a los

siguientes progiamas firmen este tbrmu'ariode consentimiento

Vivienda publica de alqmler de propiedad de una i'HA

Uportumdadcs de adquisicion de vivienda propia para cntrega lljve en

;nano de tipo II! (alquiler con opcion de compra)

Oporiumdad de adquisition de vivienda propia eon un sistema de ayudamutua.

Vivienda alquilada segun las dispflsicioncs de las Secciones 23 y 19(c)

I'agos de asistencia para vivienda segun las disposiciones de la Seccion

Vivienda de propiedad de una HA para alquiler a comumdades mdfgenas.

Cenifitado de alquiler scgun las disposiciones de la Seceion (i de la Ley

de Vivienda de los hif UU dc l«7

('upon de alquiler segun las disposiciones de la Seccion 8

Reliabihtacidn modetada segun las disposiciones de la Section 8.

Omision de la firms del formulario de consentimiento: Si listed no finna el

lormulano de consentimiento se le puede revocar su idoneidad o se le pueden

suspender los henefitios de vivienda, o ambas cosas. La revocacibn de la idoneidad

0 la suspension de los heneficios esta sujeta al procedimiento de presentation de

queias de la HA y de audiencia informal mdicados en la Seccibn 8.

1 uentes de acopio de informacion:

fntidades estatales de acopio de mformacibn sobre salanos I L-ste

consentimiento se limita a la indemnj/acibn por coneepto de salano y desempleo

que se me ha pagado penodicamente en los ultimos 5 anos cuando he recibido

bcneficios de asistencia para conseguir vivienda ) Administration de Seguridad

Sotial de los HH.UU (solamenie el HUD). (Lstc consentimiento se limita a \a

iiiformacion sobre salano y empleo independiente y sobre el pago de ingreso de

jubilation, citados en la Seccibn <il(H(IX7XA) del Cbdigo del Servicio de Rentas

Intcrnasde los LE.UU )

Servicio de Rentas Intemas de los b'.ll UU. (IRS) (solamenteel HUD) (Hste

oonsennmienlo se limita al ingreso no laboral |por eiemplo, interests y

dividendos] )

I'.inibien se puede obtcner informacion directamente de (a) los empleadores

.ictuales v antenores. sobre sueldos y salanos y (h) las instituciones financieras.

->obre ingresos no laboralcs (por eiemplo, imereses y dividendos) Tengo

eiiiendulo que la tnibrmatibn sobre ingresos oblemda dc estas I'uentes se

empleara para verificar la mformacibn proporcionada por ml, con el fin de

detcrmmar mi idoneidad para panitipar en los programas de asistencia para

conseguir vivienda y el monto de los benefitios I'or lo tanto, estc formulario de

vonsemimiento sofamente autonza la divulgacibn de informatibn dircctaniente

Je los empleadores y kis instituciones financieras por cualquier penodo de los

ultimos 5 anos tuando he recibido henefitios de asistencia para conseguir

vivienda.

organizacion solicilante guarda el original Formulario HUD-9886-Spanish (7/94)Ref. Manuales 7420.7, 7420.8 y 7465.1

< on xenlim lento: Uo> mi consent! mien to pur a permitirque el III I) o In II.\o I it it en y ohtengun informacion sobre mi* ingresos de las fucntet ciladas en este

formula rio ton el fin de \erifirar mi idoneidud > el monto de los heneflcios de fonTormidad con lo.s programas de usistcncia parii vivienda del HID. 1'i-ngo

I'nlcndido que las HA que reciban tuformiicidn sobre mis ingreson por medio del present* Tnrmulario de conscnlimienlo no pueden empleurla para denegar,

reducir o suspender la anislencia .sin efecluar primero una verificacion independiente del monto correspondienie. si realmente luve acci-so a los Tondos y cuando

se re cibieron. Ademas, se me debe dar la oportunidad de rcfular esas detcrminucitme*.

Kite ibrmulano de consenlimienio se vence I 5 meses despues de tirmarto.

Firmas:

de lamilia Tec ha

No del seeuro social (s i existe) del iclede tamiha ro familiar mavor de 1 H aflos .•cha

:ha ()in» familiar mavor de IS jflos

(itro familiar mavor de IH anos 1-ecna i )tro lamil lar mavor de I fi aflos

: )m> ramihar mavor de I X .i I ctha Ou<» I'amihar mayor de IS aflos

\vi-iO sobre fa Ley de Confidencialidad AulondarJ' i:l Depanamenio de Vmcnda y llcsarrollo Urbano iMLJDJesia aulon/ado para acopiar esla inrbrrnacionen vinud

de la Ley tic Vivienda de los EiE UU dc 1937 (Seccion 1437 et seq del I'itulo 42 del Codigo de los KE UU ), el I'itulo VI dc la Ley de Derechos Civilesde I1JM

iSeccion 2000d del Tltulo 42 del Codiyo de los HH.UU.)y la Ley de Vivienda Justa (Seccion 3601-19 del Titulo42 del Codigo de los l-E UU.) La Ley Je Vivienda y

Desarrollo Comumtano de 1987 (Seccion 3543 del I'itu!o42 del Cbdigo de los Lli.UU.) exigeque los sohcilanies y participanles prescnten el niimero de seguro social dc

^•Ada familiar mayor de sets aflos de cdad Fmahdad: lil HUD usa la mtbrmacion sobre sus mgresos y otra inlbrmacion acopiada para determmar su idoneidad, el lamaflo

jpropiado de las habiiaciones y el monto que pagara su tamilia por alquilcry servicios publicos. Otros uses: el MUD usa la inlbrmacion sobre su mgreso familiar y otra

mforinacion atopiada para avudar a admmjstrar v supcrvisar los programas de vivienda reali7.ados con asistencia de ese orgumsmo, proteger el mteres fmantiero del

(iobierno o \crilkar la exattitud de la iiilbrmacion proporcionada Ksta informacion puede divulgarse a entidades federales. csiaiales v locales idoneas, cuando proceda.

> a mvestigadores y nseales cncargados de tranntar cases civiles y pcnales y asuntos norrnativos De lo contrano. la mtbrmacion no se revdara ni divulgara tuera del

11UI). excepto en los casos permitidoso exigidos por la lev Sancion Usied debe proporcionar toda la mtbrmacion solicitada por la MA. rnclusoel numcro de seguro

social que (t-ncan o usen usied y todos los dcmas tamiliares mayores de seis aflos de edad. l:s obligatono dar el numero de seguro social dc lodos los lamihares mayores

de sets aftos dc edad; su omision ai'ectafa su idoneidad. La omision dc cualquier pane de la mtbrmacion solicitada puede hacer que sc demore o demegue la aprobacibn

cle su sohcitud por razones de idoneidad.

Sum-iones por el uso indebitlo del presente formula rio de consentimiento

Tl HUD, la HA v cualquier propietano (oempleado del HUD. la HA o el propictano) pueden estar sujetos a sanciones por divulgacion no auton/adao por uso mdebido

de la informacion acoptada con el presente Ibrmulano de consemtmicnto

hi uso de la mformacion acopiada con cl formulano HUD-9SK6 se limita a los lines citados en el mismo. Cualquier persona que, a nabiendas o micncionalmente, solicilc,

ohtenga o revele mtbrmacion de manera fraudulent sobre un solicilame o panicipante puede estar suicia a acusacion por delito menor v a imposicion de una rnulta

maxima de S3 (X)0

Cuakiuier soliciiantco panicipante afectado por la divuigacion negligentede mformacion puede miciar una accion civil por dartiis y perjmcios contra el olkial o

:y/icionano del MUD. la HA o el propietano responsable dc la divuigacion no autori7.ada o del uso mdebido. o huscar otra indemmzacion por pane dc ellos. segun

proct'da

Esfe documento es traduccidn d« on documento juridico expedido por el Departamento de Vivienda y DesairoWo Urbano (HUD), el cualproporciona esta traducci6n solamente a modo de conveniencia para que le ayude a usted a comprender sus derechos y obligaciones. Laversion en ingles es el documento oficial, legal y qua rige. Esta traduccion no constituye un documento oficial.

La organization solicitante guards el original i'ltima 2 Je 2 Formulario HUD-9886-Spaniah (7/94)Ref. Manuales 7420.7, 7420.8 y 7465,1

UTHORIZATION FOR RELEASE OF INFORMATION

Purpose: The Housing Authority of the City of New Haven and the U.S. Department ofHousing and Urban Development may use this authorization and the information obtainedwith it, to administer and enforce rules and regulations governing its housing programs.

Authorization: I authorize the release of any information (including documentation and othermaterials) pertinent to eligibility for or participation under any of the following programs: LowIncome Rental Public Housing: and Section 8 Housing Assistance Payment Program.

I authorize the above named agencies to obtain information about my family, or me which ispertinent to eligibility or participation in assisted housing programs.

information Covered: Inquiries may be made about: Child Care Expenses, Credit History,Criminal Record, Family Composition, Employment, Income, Pensions, and Assets,Federal, State or Local Benefits, Handicapped Assistance Expenses, Identity and MartialStatus, Medical Expenses, Social Security Numbers, Residences and Housing History.

Individuals, Organizations or Agencies that may release information: Any individual,organization or agency including any governmental agency may be asked to releaseinformation. For example, information may be requested from: Bank and Other FinancialInstitution; Employers - Past and Present; Landlords; Providers of: Alimony, Child Care,Child Support, Credit, Handicapped Assistance, Medical Care and Pensions/ Annuities;Schools and Colleges, Shelters, U.S. Social Security Administration, U.S. Department ofVeterans Affairs, Unemployment Agencies, Utility Companies and Welfare Agencies.

Computer Matching Notice and Consent: I agree that the above named agencies mayconduct computer-matching programs with other governmental agencies including: Federal,State or local agencies. The governmental agencies include: U.S. Office of PersonnelManagement, U.S. Social Security Administration, U.S. Department of Defense, U.S. PostalService, State Employment Security Agencies, State Welfare and Food Stamp Agencies.The match will be used to verify information supplied by the family.

Conditions: I agree that photocopies of this authorization may be used for the purposestated above. If 1 do not sign this Authorization, I also understand that my housingassistance may be denied or terminated.

Head of Household Name Signature Date

Other Adult Name Signature Date

Other Adult Name Signature Date

iect 1001 of Title 18 of the United States Code makes it a criminal offense to knowingly make lalse statements or misrepresent to any Department or Agency of

'he United Slates to any matter within its junsdiction and has established penalty of fines up to $100,000 and/or imprisonment not to exceed 5 years.

AUTORIZACION PARA OBTENER INFORMACIONElpmposito: La Autoridad de Viviendade la Ciudad de New Haven (HANH) y El departamento deEnvoltura y Desarrollo Urbano (HUD) puede utilizar esta autorizacion y la informacion obtenida, paraadministrar e imponer las reglas y las regulaciones que gobiernan sus programas de envoltura.

Autonzacion: Yo autorizo la liberacion de cualquier informacion (incluyendo la documentacion y otrosmateriales) pertinente a la elegibilidad para o para la participacion bajo cualquiera de los programassiguientes: Vivienda Publica y la Asistencia de Renta de Seccion 8.

Yo Autorizo HANH y HUD obtener informacion acerca de mi o mi familia que es pertinente a laelegibilidad o la participacion en los programas de asistencia de vivienda.

La informacion Cubrira: Informacion obtenida puede ser acerca de: los Gastos del Cuidado de Nino, laHistoria del Credito, el Registro Criminal, la Composicion de la Familia, el Empleo, los Ingresos, lasPensiones, y las Ventajas, Beneficios local, Federal, o del Estado, los Gastos de Ayuda por Incapacitado,la Identidad y la Posicion Marcial, los Gastos Medicos, los Numeros del seguro social, la Historia devivienda y residencias.

Los individuos, las Organizaciones o las Agendas que pueden liberar informacion: Cualquier individual,organizacion o agenda incluyendo gubernamental puede liberar informacion. Por ejemplo, la informacionse puede solicitar de: el Banco y Otra Institution financiera; Empleadores - Pasado y Presente;Propietarios; Proveedores de: Pension, el Cuidado de Nino, Apoyo de Nino, el Credito, Ayuda parIncapacidad, el Cuidado y las Pensiones Medicos/ las Anualidades; tas Escuelas y los Colegios, losRefugios, los EE.UU. La Administracion de la Segundad Social, los EE.UU. El Departamento de Asuntosde Veteranos, las Agendas del Desempleo, las Companias de la Utilidad y Agencias de Bienestar.

La computadora que Empareja y Note: Estoy de acuerdo que la agencia denominada puede conducir lacomputadora emparejar los programas con otras agencias gubernamentales incluyendo: Federal, elEstado o las agencias locales. Las agendas gubernamentales incluyen: los EE.UU. La Oficina de laDireccion Personal, los EE.UU. La Administracion de la Seguridad Social, los EE.UU. El Departamento dela Defensa, los EE.UU. El Servicio Postal, las Agencias de la Seguridad del Empleo del Estado, elBienestar del Estado y Agencias de Sello de Alimento. El igual se utilizara para verificar informacionsuministrada por la familia.

Las condiciones: Estoy de acuerdo que las fotocopias de esta autorizacion se pueden utilizar para elproposito indicado arriba. Si yo no firmo esta Autorizacion, yo entiendo tambien que mi ayuda de envolturase puede negada o puede ser terminada.

Jefe del Hogar Firma Fecha

Otro Adulto Firma Fecha

Otro Adulto Firma Fecha

Tenant Certification for HANH Use Only

Giving True and Complete Information!\We certify that all the information provided to the Housing Authority of the City of New Haven on householdcomposition, income , net family assets and items for allowance and deductions is accurate and complete to the bestof my\r knowledge and belief.

!ncome\Family Composition Informationl\We understand that I am to notify my caseworker at the Housing Authority within 14 days of the change in wnting, Ifthe current status of my household income changes by two hundred dollars ($200.00) or more per month and\or itthere had been any changes in my family composition household size when a person moves in or out of the unit.

VisitorsVisitors are permitted in a dwelling unit in accordance with HANH's Procedure on Visitors so long as they have noprevious history of behavior on HANH premises that would be a lease violation.

At all HANH Properties, a guest may visit for no more than 14 days in any twelve month period.

No Duplicate Residence or AssistanceIWVe certify that the house or apartment will be my principal residence and that I will not obtain duplicate FederalHousing Assistance while I am in this program. I will not sublease my assisted residence. I understand that I mustprovided proper notification to the Housing Authohty of the City of New Haven of my intent to vacate my subsidized.

CooperationIWVe know I am required to cooperate in supplying all information needed to determine my eligibility, level of benefitsor verify my true circumstances. Cooperation includes attending pre-scheduled meeting\inspections and completingand signing needed forms. I understand failure to do may result in delays, termination of tenancy and termination ofassistance.

Criminal and Administrative Actions for False InformationIWVe understand that knowingly supplying false, incomplete or inaccurate information is punishable under Federaland\or state law. I also understand that knowingly supplying false, incomplete or inaccurate information is grounds fortermination of housing assistance or termination of tenancy.

IWVe understand that failure to comply with all of the above mentioned on this application will cause me\us to beterminated from the Public Housing Program.

Head of Household Printed Name Signature Date

HANH Staff Printed Name Signature Date

Sec 1001 of Title 18 of the United States Code makes it a criminal offense to knowingly make false statements ormisrepresent to any Department or Agency of the United States to any matter within its Jurisdiction and hasestablished penalty of fines up to $100,000 and\or imprisonment no to exceed 5 years.

Certificacion del inquilino parauso exclusive de HANH

Presentation de informacion veraz y com pi etaEl que suscnbe certifica que toda la informacion presenlada ante la Autoridad de Vivienda de la Ciudad de New Haven'especto de la composicion del hogar, ingresos, actives famitiares netos y elementos para asignaciones y deducciones esveraz y compteta a su leal saber y entender.

Informacion sobre los ingresos/composicion del grupo familiarEl que suscribe comprende que debe notificar por escrito a su asistente social de la Autoridad de Vivienda dentro de los14 dias de producido el cambio, en case de que !a condicion actual de los ingresos del hogar se modificare por doscientosdolares ($200,00) o mas por mes y/o hubiere modificaciones en la composicion de! grupo familiar cuando una persona semude a la unidad o la abandone.

VisitasSe oermiten las visitas a una unidad de vivienda conforme al Procedimiento de visitas de HANH, siempre que las mismas;io cuenten con un histonal previo de conductas en las instalaciones de HANH que constituyan una violacidn al contratode alquiler.

En todas las instalaciones de HANH, un invitado no podra alojarse en una unidad durante mas de 14 dias en un periodode doce meses.

No se permiten las residencias o asistencias duplicadasEl que suscribe certifica que la casa o departamento sera su principal residencia y que no obtendra otra Asistencia federalpara la vivienda mientras permanezca inscripto en este programa. El que suscribe no subalquilara su residencia asistida.Comprende que debe bn'ndar un aviso adecuado a ta Autoridad de Vivienda de la Ciudad de New Haven sobre suintencion de desocupar su vivienda subsidiada.

ColaboracionEl que suscribe tiene conocimiento de que se requtere su colaboracion para presentar toda la informacibn necesaria a finde determinar su elegibilidad, nivel de beneficios o verificar la veracidad de sus circunstancias. La colaboracion incluyeasistir a reuniones/inspecciones programadas y completar y firmar los formularies necesarios. El que suscribe comprendeque su incumplimiento en este aspecto podra resultar en demoras, rescision del contrato de alquiler y de la asistencia.

Acciones penales y administrativas por falsa informacionEl que suscnbe comprende que la entrega consciente de informacion falsa, incompleta o imprecisa esta penada por la leypenal federal y/o estatal. Asimismo, comprende que la entrega consciente de informacion falsa, incompleta o imprecisaconstituye causa suficiente para extinguir la asistencia para la vivienda o el contrato de alquiler.

E! que suscnbe comprende que el incumplimiento de todo lo mencionado en la presente solicitud podra resultar ensu expulsion del Programa de viviendas publicas.

Jefe de hogar (Nombre en letra de imprenta) Firma Fecha

Empleado de HANH (Nombre en letra de imprenta) Firma Fecha

El Articulo 1001 del Titulo 18 del C6digo de los EE. UU. tipiflca como delito penal realizar falsas declaraciones ante todoOepartamento o Entidad de los EE. UU. en relacidn a cuestiones dentro de su competencia y ha establecido una penade multas de hasta $100.000 y/o penas de prisibn que no excedan los 5 afios.

NEW JOB'ITHOUT HIGH RENT INCREASE (MUST ENROLL IN FSS)

LEARN ABOUT THE EARNED INCOME DISREGARD

Federal public housing tenants and only disabled Section 8 participants who have their income increase becauseof a new job or better wages may qualify for an Earned Income Disregard. This means that, in calculating monthly rent,the Housing Authority would not count increased family income due to wages. Residents/Participants qualify for theEarned Income Disregard if, when they got the new job or their wages went up, they had been:

• Unemployed for a year or more, or earned less than $3,200 in the past year; or• In job training or some other economic self - sufficiency program; or• Getting TANF welfare benefits within the past six months.

If you qualify for the Earned Income Disregard, the Housing Authority will not raise your rent because of increased familyincome due to wages. Non - wage income, such as child support or public benefits, is not eligible for the disregard.

The Earned Income Disregard is good for 24 months. It goes in steps:

1. For the first 12 months, all increased income due to wages will be disregarded(not counted toward your rent).

2. For the next 12 months, the Housing Authority will disregard 50% of the increased income due to wages. If you stopworking, you can stop the clock on the 24 - month period and restart it when you go back to work. However, you haveonly 4 years from the time you first qualify for an Earned Income Disregard to use up your 24 months of benefits.

Child Care Costs May Also Lower Your Rent. The money you pay for childcare may be deducted from your incomewhen HANH calculates your rent. You do not have to be eligible for the Earned Income Disregard to get a child carededuction. This deduction is available to all working families and those enrolled in education and training programs.

How Do / Get The Earned Income Disregard Or Child Care Deduction?

The Housing Authority should determine your eligibility for an Earned Income Disregard and the amount of any childcarededuction whenever you report income from employment. You should bring in proof of your employment and wages and(for the child care deduction) proof of your child care costs. If you still disagree, ask for a grievance hearing (in writing).

have received and read the flier titled "NEW JOB" regarding Earned Income Disregard and

I do not feel that I am entitled to the Earned Income Disregard

I feel that I am entitled to the Earned Income Disregard

Resident/Participant Signature Tenant Social Security # Date

1001 of Title 18 of rtie United Slates Code makes it a criminal offense to knowingly make false statements or misrepresent to any Department or Agency of

;he United States to any matter within its jurisdiction and has established penalty of fines up to $100, 000 and/or imprisonment not to exceed 5 yeara.

HOUSING AUTHORITY OF THE CITY OF NEW HAVEN

YOUR RIGHT TO REQUEST ACCOMMODATIONS OF DISABILITY

Persons with disabilities have the right to request reasonable accommodations

Federal laws provide specific rights and protections to ensure equal opportunity for persons with disabilities. HANH will make

reasonable accommodations in our rules, policies, practices, or services, including modifications to our public housing

apartments, when such accommodations are necessary to afford a person with disabilities equal opportunity to use and enjoy

their housing, or to equally participate in or access HANH's housing programs and services.

How to request an accommodation of disability

HANH's "Request for Accommodation of Disability" form provides the necessary information and authorizations. HANH's

reasonable accommodation forms are available at all HANH offices. HANH will provide assistance if needed to help you

complete these forms.

You should receive a written response to your request within 30 days. If HANH is not able to make a decision on your request

within that time period, or if HANH requires further verification, HANH will notify you in writing.

HANH will require verification of your request

HANH requires the following verifications of requests for accommodations of disability by a physician or other licensed practioner

that you have authorized for this purpose.

• Verification that the person is a qualifying person with disabilities.

• Verification that there is a direct relationship between the nature of the person's disabilities and the accomadation

requested.

• Verification that the accommodation is necessary for the person to have equal opportunity to use and enjoy their HANH

housing, or to equally participate in or access HANH's housing programs and services.

HANH has established a "Verification of Accommodation Request" form that your doctor or licensed practitioner should use to

provide verification. This form is available at all HANH offices. Approval of reasonable accommodation requests will depend upon

verification of the specific standards that are specified in the "Verification of Accommodation Request" form. You may submit

doctor's letters, but please note that doctor's letters often do not include the specific verifications required for reasonable

accommodations and, in most cases, will require additional verification of the standards provided in the "Verification of

Accommodation Request" form.

HANH's Reasonable Accommodation Coordinator

If you have questions or would like additional information about accommodation request, you may contact HANH's Reasonable

Accommodation Coordinator:

Teena Bourdeaux

1160 Orange Street

new Haven, CT 06511

Phone: (2031498-8800 Ext 1507

=nx-1203) 497 8728

Email: tbourdeaux@hanh-ct.orq

HOUSING AUTHORITY OF THE CITY OF NEW HAVEN

YOUR RIGHT TO REQUEST ACCOMMODATIONS OF DISABILITY

Las personas con incapacidades tienen el derecho de pedir comodidades razonables

Las leyes federates proporcionan los derechos y protecciones especificas de asegurar laigualdad de oportunidades para las personas con incapacidades. HANH hara comodidadesrazonables en nuestras reglas, politicas, practicas, o servicios, incluyendo modificaciones anuestros apartamentos de vivienda cuando tales comodidades son necesarias a una personacon incapacidades dar oportunidades de igualdad para utilizar y gozar de su vivienda, oparticipara igualmente adentro o tendra acceso a los programas y de los servicios de cubiertade HANH

i,C6mo pedir una comodidad por alguna incapacidad?

La forma de HANH el "Request for Accommodation fo Disability" provee la tnformacion y lasautorizaciones necesarias. Esta forma esta disponible en todas las oficinas de HANH. HANHfacilitara ayuda si es necesario para llenar el formulario.

Usted debe recibir una respuesta escrita a su peticion en el plazo de 30 dias. Si HANH nopuede tomar una decision a su peticion dentro de ese plazo, o si HANH requiere verificacionadicional, HANH le notificara por escrito.

HANH requerira la verificacion a su peticion

HANH requiere las verificaciones siguientes a su peticion para las comodidades razonables deincapacidades a su medico o de otro medico que usted ha autorizado para este fin.

• Verificacion que la solicitante es una persona con incapacidades.• Verificacion que hay una relacion directa entre la naturaleza de las incapacidad de lapersona y la comodidad solicitada.• Verificacion que la comodidad es necesaria para que la persona tenga igualdad deoportunidades de utilizar y de gozar de su vivienda, o participar igualmente adentro otener acceso a los programas y a los servicios de cubierta de HANH.

HANH ha establecido una forma para la "verificacion de la peticion de comodidad" que sudoctor o medico autorizado debe utilizar para proporcionar la verificacion. Esta forma estadisponible en todas las oficinas de HANH. La aprobacion de las peticiones razonables de lacomodidad dependera de la verificacion y los estandares especificos que se detallan en laforma. Usted puede someter cartas de su doctor, favor de observar que las cartas del doctor noincluyen a menudo las verificaciones especificas requeridas para las comodidades razonablesy, en la mayoria de los cases, no requeriran la verificacion adicional de los estandaresproporcionados.

Coordinador de HANH para la solicitud de las comodidades razonable es:

De tener alguna pregunta o de necesitar alguna informacion adicional sobre su solicitud estapeticion de comodidad, usted puede comunicarse con la coordinador de HANH:

Teena Bordeaux360 Orange Street, New Haven, CT 06511Phone: (203) 498-8800 ext. 1507Fax: (203) 497-8728Email: tbordeaux@hanh-ct.org

Application for Tiered Rent WaiverHardship Exemption

Consistent with HANH's Moving to Work Rent Simplification Policy, Households thatare experiencing exceptional expenses that create a financial hardship may request a rentreduction. Rent reductions must be based upon financial hardship related to extraordinarydeductions or extraordinary cost of living. This request is to be furnished in writing.

Extraordinary DeductionsA hardship review and rent reduction can be requested by the family if its un-reimbursedmedical, un-reimbursed childcare expenses and/or un-reimbursed disability attendant careand auxiliary apparatus expenses exceed $6,000.00 annually.

Extraordinary Cost of LivingA hardship review and rent reduction can be requested by the family if its monthly totalshelter costs {lenant paid rent plus paid utilities), when combined with un-reimbursedmonthly medical expenses, as determined in accordance with 24CFR Part 5.611 (a)(3)(i),disability attendant care and apparatus allowance, as determined in accordance with 24CTR Part 5.611 (a)(3)(ii) and/or reasonable childcare expenses as determined inaccordance with 24 CFR Part (a)(4), exceed forty (40%) of a family's monthly income(monthly income is defined as Annual Income divided by twelve).

All requests for Hardship Review and rent reductions shall be referred to and reviewed bythe Hardship Committee. Should a resident request hardship review but fail to attend thescheduled meeting, one opportunity to reschedule will be provided. If the resident fails toattend the second scheduled appointment no further attempts to reschedule will be madeand HANH w i l l determine that no hardship exists.

Tiered Rent Waiver Application

Application for Tiered Rent WaiverHardship Exemption

Please check either Yes or No

Yes, I want to apply for a Hardship Review for Exceptional Expenses

No, I do not want to apply for a Hardship Review for ExceptionalExpenses

Please fill in below:

Mame:

Address:

City, State, Zip:

Telephone #:

Signature: Date:

Reason:

HANH Representative Signature

Tiered Rent Waiver Application7/12

Application - Exemption from Minimum Rent of $50

For Households that are currently paying the Minimum Rent of $50,00:Households with an annual income below $2,500 annually shall pay the minimumrent of $50.00. All families placed on minimum rent must be informed of theExemption from Minimum Rent and the ability to have Minimum Rent waived. Allresidents on minimum rent with the exception of elderly and person withdisabilities must be referred to the Family Self Sufficiency Program.

If a family is unable to pay the minimum rent because of a financial hardship thefamily may be eligible for a temporary or long term waiver from paying MinimumRent. Minimum Rent can be waived once during a twelve month period. Thislimitation does not apply to Elderly and Disabled families. Families may receivethis exemption more than once during a twelve month period if at least one adult isengaged in the Family Self Sufficiency Program. HANH will suspend theminimum rent requirement for 90 days effective as of the first of the nextmonth after the date this application is received.

A family is automatically exempt from Minimum Rent for 90 days when thefollowing occurs:

1. When the family has lost eligibility or is awaiting eligibility determinationfrom a Federal, State or local assistance.

2. When the family would be evicted because it is unable to pay the minimumrent.

3. When the income of the family has decreased because of changingcircumstances, including loss of employment, death, or other event.

4. Other circumstances determined by HANH to be reasons to waive theminimum rent requirement.

While the request for exemption from Minimum Rent is reviewed, HANH willnot pursue eviction for non-payment of rent.

For Long Term exemption from minimum rent (more than 90 days), the minimumrent is suspended immediately until the Hardship Committee meets to determinewhether the hardship is temporary or long term and implements a recommendation.

\pplicalion for MR Exemption1' 12 ER

It"the exemption from the minimun rent of $50 is determined to be temporary youwi l l have the right to enter into a reasonable repayment agreement with HANH forthe amount of the minimum rent that was suspended,

Any family that is unable to attend the meeting due to a disability may requesta Reasonable Accommodation. Please contact Teena Bordeaux at 203-498-8800X1507.

A p p l i c a t i o n Ibr MR Exemption~ 12 LR

Application - Exemption from Minimum Rent

Please check either Yes or No

Yes, I want to apply for Exemption from Minimum Rent.No, I do not want to apply for Exemption from Minimum Rent.

Please fill in below:

Name:

Address:

City, State, Zip:

Telephone #:_

Signature: _^^__________ Date:

Reason:

Name of HANI I Representative

A p p l i c a t i o n for MR KxemplionT i: i 'R

NO-INCOME AFFIDAVIT

Date: Recert Month:

Head of Household Name:

Applicant/Tenant Name: _

Address:

SSN:

i j f * ELM CITYI 1 J 1 communitiesHousing Authority of New Haven

Karen DuBois-Walton

Executive Director

You are either an applicant for, or participant in, a federally funded housing assistance program. Pleaseprovide the information requested and return to our office personally or via mail in the enclosed self-addressed stamped envelope as quickly as possible to avoid delay of your benefits in the housing ChoiceVoucher Program (Section 8).If you have any questions, please call at (203) 498-8800, Ext

'LEASE NOTE: THIS FORM MUST BE NOTARIZED

j hereby swear and affirm that I do NOT have any income. ThisIincludes but is not limited to income from any of the following:

1. Wages, Public Assistance (TANF, GR, etc.). Social Security, SSI, etc.;2. Child Support, Alimony, or regular monetary gifts from family or friends, etc.;3. Assets (homes, stocks, etc.; may be inherited property);4. Interest Income from Savings, Checking, Christmas Club and other bank accounts, IRA's, Certificates of

Deposit, Money market Funds, Credit Unions, etc.;5. U. S. Saving Bonds, Stocks or Bonds of any kind;6. Pensions, Annuities, Retirement Funds, etc. (this includes benefits you may receive from being a

beneficiary of a life insurance or retirement plan);7. Whole Life Insurance;8. Real Estate Property, Earned Income Tax Credit, etc,;9. Burial Plots; and/or10. ANY OTHER INCOME (includes tips, property sold, babysitting, etc.).

Applicant/Participant Signature: Date

Subscribed and sworn to before me, a Notary Public, in and for County of

and State of Connecticut, on

this day of , 20 .

Notary Public Signature

AFFIX SEAL HERE

My Commission Expires.

Housing Authority of the City of New Haven's Elm City Communities360 Orange Street, P.O. Box 1912, New Haven, CT 06511(203) 498-8800 • TTD (203) 497-8343 • www.newhavenhousinq.org

WARNING! I'tile 18, Section 1001 of the United States Code, states that ;i person uho kno\ irmly and \vi Mindly makes IUI.sefraudulent statements to any department or agency of the United States Government is guilty of a felony.

DECLARAC1ON DE NINGUN INGRESO

I'echa: Mez dc Recert: lili ELM CITYcommunities

Nombre De Participante:

Direccion

NSS:

Ciudad/Fstado

Housing Authority of New Haven

Karen DuBois-WaltonExecutive Director

Usted es tin sniicitante o participate en un programa de ayuda de vivienda fondada federalmente. Favor deproporcionar la information requerira a nuestra oficina personalmente o via el correo en el sobre estampado,auto dirigido y encerrado tan rapidamente como posible para evitar la demora de sus beneficios en elprograma de Secci6n 8 Vivienda Publica Otro programa patrocinados. Si usted tiene cualquiera pregunta,por favor de llamar al (203) 498-8800, Ext .

'OTICIA: ESTE FORMULARIO TIENE QUE NOTARISADA

Yo, _._^_^___^_^___^_^_____^_ . juro y contirmo que yoNO tengo ingreso. Esto incluye pero no es limitado a ingreso de cualquier de lo siguiente:

1. Los sueldos, la Ayuda Estatal (TANF, GR, etc.), el Seguro Social, SSI, etc.;2. El Apoyo del nino, la Pension, regalos monetarios regulares de la familia o amigos, etc.;3. Las vcntajas (hogares, las acciones, etc.; la propicdad puede ser heredada);4. Ingresos de Interese de Ahorros, Cuenta Correntie, el Club de la Navidad y otras cuentas

bancarias, IRA's, los Certificados de deposito, los Fondos del mercado monetario,Acreditan las Uniones, etc.;

5. Bonos de E.U., las Acciones o Vincula de cualquier tipo;6. Las pensiones, las Anualidades, los Fondos de la Jubilacion, etc. (Esto incluye los

beneficios que usted puede recibir de benellciario de un plan de seguros de vida o jubilacion);7. Los Seguros de vida enteros;8. La Propiedad de bienes raices, el Credito Ganado de Impuesto de renta, etc,;9. El entierro Frama; y/o10. CUALQUIER OTROS INGRESOS (incluye puntas, la propiedad vendio, el cuido de

ninos, etc.)Firma de Solicitante/Participante Fecha

Subscribed and sworn to before me, a Notary Public, in and for County of

and State of Connecticut, on

this day of , 20 .

Notary Public Signature

My Commission Expires

AFFIX SEAL HERE

Housing Authority of the City of New Haven's Elm City Communities360 Orange Street, P.O. Box 1912, New Haven, CT 06511(203) 498-8800 • TTD (203) 497-8343 • www.newhavenhousing.org

W \RN1NO! Title IS. Section 1001 of the United Stales Code, stales that LI person who knowingly and willingly makesfraudulent statements lo an> department or agency ot'the United States Government is guilty ot'a felony.

OMB No. 2577-0266 Expires 04/30/2013

U.S. Department of Housing and Urban DevelopmentOffice of Public and Indian Housing

DEBTS OWED TO PUBLIC HOUSING AGENCIES AND TERMINATIONSPaperwork Reduction Notice: The information collection requirements contained in this notice have been approved by theOffice of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3520) and assigned OMBcontrol number 2577-0266. In accordance with the Paperwork Reduction Act, HUD may not conduct or sponsor, and aperson is not required to respond to a collection of information unless the collection displays a current valid OMB controlnumber.

NOTICE TO APPLICANTS AND PARTICIPANTS OF THE FOLLOWING HUD RENTAL ASSISTANCE PROGRAMS:

• Public Housing (24 CFR 960)• Section 8 Housing Choice Voucher, including the Disaster Housing Assistance Program (24 CFR 982)• Section 8 Moderate Rehabilitation (24 CFR 882)

• Project-Based Voucher (24 CFR 983)

The U.S. Department of Housing and Urban Development maintains a national repository of debts owed to PublicHousing Agencies (PHAs) or Section 8 landlords and adverse information of former participants who have voluntarily orinvoluntarily terminated participation in one of the above-listed HUD rental assistance programs. This information ismaintained within HUD's Enterprise Income Verification (EIV) system, which is used by Public Housing Agencies (PHAs)and their management agents to verify employment and income information of program participants, as well as, toreduce administrative and rental assistance payment errors. The EIV system is designed to assist PHAs and HUD inensuring that families are eligible to participate in HUD rental assistance programs and determining the correctamount of rental assistance a family is eligible for. All PHAs are required to use this system in accordance with HUDregulations at 24 CFR 5,233.

HUD requires PHAs, which administers the above-listed rental housing programs, to report certain information at theconclusion of your participation in a HUD rental assistance program. This notice provides you with information on whatinformation the PHA is required to provide HUD, who will have access to this information, how this information is usedand your rights. PHAs are required to provide this notice to all applicants and program participants and you arerequired to acknowledge receipt of this notice by signing page 2. Each adult household member must sign this form.

What information about you and your tenancy does HUD collect from the PHA?The following information is collected about each member of your household (family composition): full name, date ofbirth, and Social Security Number.

The following adverse information is collected once your participation in the housing program has ended, whether youvoluntarily or involuntarily move out of an assisted unit:

1. Amount of any balance you owe the PHA or Section 8 landlord (up to $500,000) and explanation for balance owed(i.e. unpaid rent, retroactive rent (due to unreported income and/ or change in family composition) or other chargessuch as damages, utility charges, etc.); and

2. Whether or not you have entered into a repayment agreement for the amount that you owe the PHA; and3. Whether or not you have defaulted on a repayment agreement; and4. Whet her or not the PHA has obtained a judgment against you; and5. Whether or not you have filed for bankruptcy; and6. The negative reason(s) for your end of participation or any negative status (i.e. abandoned unit, fraud, lease

violations, criminal activity, etc.) as of the end of participation date.

April 26, 2010 FormHUD-52675

OMB No. 2577-0266 Expires 04/30/2013

Who will have access to the information collected?This information will be available to HUD employees, PHA employees, and contractors of HUD and PHAs.

How will this information be used?PHAs will have access to this information during the time of application for rental assistance and reexamination offamily income and composition for existing participants. PHAs will be able to access this information to determine afamily's suitability for initial or continued rental assistance, and avoid providing limited Federal housing assistance tofamilies who have previously been unable to comply with HUD program requirements. If the reported information isaccurate, your current rental assistance may be terminated and your future request for HUD rental assistance may bedenied for a period of up to ten years from the date you moved out of an assisted unit or were terminated from a HUDrental assistance program.

How long is the debt owed and termination information maintained in EIV?Debt owed and termination information will be maintained in EIV for a period of up to ten (10) years from the end ofparticipation date.

What are my rights?In accordance with the Federal Privacy Act of 1974, as amended (5 USC 552a) and HUD regulations pertaining to itsimplementation of the Federal Privacy Act of 1974 (24 CFR Part 16), you have the following rights:1. To have access to your records maintained by HUD.2. To have an administrative review of HUD's initial denial of your request to have access to your records maintained

by HUD.3. To have incorrect information in your record corrected upon written request.4. To file an appeal request of an initial adverse determination on correction or amendment of record request within

30 calendar days after the issuance of the written denial.5. To have your record disclosed to a third party u pon receipt of your written and signed request.

What do I do if 1 dispute the debt or termination information reported about me?You should contact the PHA, who has reported this information about you, in writing, if you disagree with the reportedinformation. The PHA's name, address, and telephone numbers are listed on the Debts Owed and Termination Report.You have a right to request and obtain a copy of this report from the PHA. Inform the PHA why you dispute theinformation and provide any documentation that supports your dispute. Disputes must be made within three yearsfrom the end of participation date. Otherwise the debt and termination information is.presumed correct. Only thePHA who reported the adverse information about you can delete or correct your record.

Your filing of bankruptcy will not result in the removal of debt owed or termination information from HUD's EIV system.However, if you have included this debt in your bankruptcy filing and/or this debt has been discharged by thebankruptcy court, your record will be updated to include the bankruptcy indicator, when you provide the PHA withdocumentation of your bankruptcy status.

The PHA will notify you in writing of its action regarding your dispute within 30 days of receiving your written dispute.If the PHA determines that the disputed information is incorrect, the PHA will update or delete the record. If the PHAdetermines that the disputed information is correct, the PHA will provide an explanation as to why the information iscorrect.

This Notice was provided by the below-listed PHA: I hereby acknowledge that the PHA provided me with theDebts Owed to PHAs & Termination Notice:

Signature

Printed Name

Date

April 26, 2010 FormHUD-52675

DECLARATION OF SECTION 214 STATUS

Notice to applicants and tenants: In order to be el igible to receive the housing assistancesought, each applicant for or recipient of housing assistance must be lawfully within theUnited States. Please read the Declaration statement carefully and sign and return to theHousing Authority's Admissions Office. Please feel free to consult with an immigrationlawyer or other immigration expert of your choosing.

certify, under penalty of perjury, that tothe best of my knowledge, I am lawfully within the United States because:

[ ] 1 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).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 andsigned verification consent form.

[ J I mmigrant status under # 1001 (a)( 15) or 101 (a)(20) of the IN AOR:[ 1 Permanent residence under #249 of INAOR:1 j Refugee, asylum or conditional entry status under #207, 208 or 203 of the

INAOR:| ] Parole status under #2l2(d)(f) of the INAOR:[ ] Threat to life of freedom under #243(h) of the INAOR:

Amnesty under #254 of the INA

Signature of Family Member Date

[ ] Check box if signature of adult residing in the unit is responsible for a child named onstatement above.

HA: Enter INS/SAVE Primary Verification # _ __ Date_

Warning: 18 U.S.C. 1001 provides, among other things, that whoever knowingly andwi l l fu l ly makes or uses a document or writing containing any false, fictitious or fraudulentstatement or entry, in any manner within the jurisdiction of any department or agency ofthe United States, shall be lined not more than SI0,000 or imprisoned for not more than fiveyears, or both.

[See reverse side for footnotes and instructions)

['he following footnotes pertain to noncitizens that declare eligible immigration status inone of the following categories:

Eligible immigration status and 62 years of age or older: For noncitizens who are 62 years ofage or older or who w i l l be o2 years of age or older and receiving assistance under a Section 214covered program on June 19, 1995. If you are eligible and elect to select this category, you mustinclude a document providing evidence of proof of age. No further documentation of eligibleimmigra t ion status is required.

Immigrant status under I U U a ) ( l 5 ) or I Q l ( u K 2 0 ) of INA: A noncitizen lawful ly admitted forpermanent residence, as defined by I0!(a)(20) of the Immigration and Nationality Act ( I N A ) , as'.in immigrant, as defined by 10l(a)( 15) of the INA(8 U.S.C. 1 IOI ( a ) (2 0 ) and 1 101(a)(15), respectively [immigrant status). This category includes anoncitizen admitted under 210 or 21OA of the IN A (8 U.S.C. 1160 or 1161), [special agriculturalworker status] who has been granted lawful temporary resident status.

Permanent residence under 249 of INA: A noncitizen who entered the U.S. before January I,1972, or such later date as enacted by law, and has continuously maintained residence in the U.S.since then, and who is not ine l ig ib le for citizenship, bur who is deemed to be lawfully admittedfor permanent residence as a result of an exercise of discretion by the Attorney General under 249of the INA (8 U.S.C. 1259) [amnesty granted under INA 249].

Refugee, asylum or conditional entry status under 207, 208 or 203 of INA: A noncilizen whois 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 ofthe INA (8 U.S.C. 1 158) [asylum status]; or as a result of being granted conditional entry under203(a)(7) of the INA (U.S.C. 1 153(a)(7) before Apri l I, 1980, because of persecution or tear ofpersecution on account of race, religion or political opinion or because of being uprooted bycatastrophic national calamity [conditional entry status].

Parole status under:2J_2(d)(51 of INA: A noncitizen who is lawfully present in the U.S. as aresult of an exercise of discretion by the Attorney General for emergent reasons or reasonsdeemed strictly in the public interest under 2l2(d)(5) of the INA (8 U.S.C. 1182(d)(5) [parolestatus j.

Threat tojifc or freedom under 245(a) of IN A: A noncitizen who is lawfully present in theU.S. as a result of the Attorney General's withholding deportation under 243(h) of the INA (8U.S.C. I253(h)) [threat to l ife or freedom).

Amnestxuj!der._245(a) of the INA: A noncitizen lawfully admitted for temporary' or permanentresidence under 245(a) of the INA (8 U.S.C. 1255(a)) [amnesty granted under INA 245(a)|.

Instructions to Housing Authority: Following verification of status claimed by personsdeclaring el igible immigrat ion status (other than for noncitizens age 62 or older and receivingassistance on June 19, 1995), the HA must enter INS/SAVE Verification Number and date thatit was obtained. An HA signature is not required.

Instructions to Family Member for Completing Form: On opposite page, print or type firstname, middle initial(s) and last name. Place an "x11 in the appropriate boxes. Sign and date atbottom page. Place an "X" in the box below the signature if the signature is by the adultresiding in the un i t who is responsible for the child.