DOCUMENTATION NEEDED TO COMPLETE APPLICATION

YOU MUST BRING COPIES OF EACH ITEM LISTED BELOW

1. ___ BIRTH CERTIFICATE OR VOTER’S REGISTRATION CARD

2. ___PROOF OF CITIZENSHIP STATUS (if applicable)

3. ___AWARDS LETTER FROM SOCIAL SECURITY OFFICE (if applicable)

4. ___PROOF OF INCOME ( CURRENT CHECK STUBS, MUST HAVE 3)

5. ___BACKGROUND CHECK FROM SHERIFF’S OFFICE AND DISTRICT COURT OF THE COUNTY YOU HAVE RESIDED IN FOR THE PAST 6 MONTHS. (BACKGROUND CHECKS ARE ALSO ACCEPTED FROM LOCAL POLICE DEPARTMENT OR STATE DEPARTMENT) PLEASE PROVIDE AT LEAST TWO.

6. ___ COPIES OF SOCIAL SECURITY CARDS FOR EACH MEMBER OF THE HOUSEHOLD

7. ___ COPIES OF STATE OR FEDERAL PICTURE ID FOR ALL ADULTS IN THE HOUSEHOLD (EXAMPLE: DRIVERS LICENSE)

8. ___ CHLD SUPPORT VERIFICATION FROM CHILD SUPPORT ENFORCEMENT

9. ___ FOOD STAMP LETTER FROM DHS

10. ___SIGNED 214 DOCUMENT FOR EACH MEMBER OF THE HOUSEHOLD

HOT SPRINGS HOUSING AUTHORITY APPLICATION FOR HOUSING ASSISTANCE

The Hot Springs Housing Authority offers two types of rental assistance:

1. Public Housing – 245 family housing units from 1 to 4 bedrooms located in Eastwood Gardens/Eastwood Heights, Mountainview Towers houses 120 Elderly, Handicapped and Disabled Units (Efficiencies and couples apartments)

2. Section 8 – 658 Vouchers, which provide rental assistance in PRIVATELY OWNED Houses, Apartments and Mobile Homes in Garland County

The Housing Authority DOES NOT provide funds for the repairs or rehabilitation of homes, nor do we assist with the purchase of homes.

ELIGIBILITY INCOME LIMITS

FAMILY SIZE SECTION 8 and PUBLIC HOUSING

1 $25,700.002 $29,400.00 3 $33,050.004 $36,700.00 5 $39,650.006 $42,600.00 7 $45,550.008 $48,450.00

THE ATTACHED APPLICATION MUST BE COMPLETED and either mailed or brought into our office. Office hours are 7:00 A.M. - 5:30 P.M. Monday through Thursday. Applications must be turned in by 3:30 P.M. EVERYONE OVER THE AGE OF 18 WILL NEED TO SIGN THE APPLICATION AND BRING IN A CURRENT BACKGROUND CHECK. THE BACKGROUND CHECK MUST BE FROM THE COUNTY IN WHICH YOU HAVE RESIDED IN THE LAST 6 MONTHS. YOU WILL NEED A BACKGROUND CHECK FROM THE SHERIFF DEPARTMENT AND THE DISTRICT COURT. IN ADDITION, ANYONE IN YOUR HOUSEHOLD EIGHTEEN YEARS OF AGE OR OLDER WILL NEED TO BRING IN A VALID PICTURE ID. Our Mailing Address is PO Box 1257, Hot Springs, AR 71902.

IMPORTANT NOTICE: IF APPLICATION IS NOT COMPLETELY FILLED OUT WITH REQUIRED DOCUMENTATION, IT WILL NOT BE PROCESSED.

Revised 12/23/2013

PLEASE INDICATE THE PROGRAM(S) FOR WHICH YOU WISH TO APPLY:

Section 8 ____ Public Housing______ Public Housing Mountainview Towers______

PLEASE SELECT ALL THAT APPLY:

Preferences: Elderly/Disabled_____ Working Family___

____Veteran________ Displaced_____ Do you have a request for any reasonable accommodations due to disabilities?

Yes______ No________

If yes explain:___________________________________________________________

PHA USE ONLY:

Date Application Received:_________________ Time Application Received:_____________

Staff Initials:__________________

12-23-2013

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Hot Springs Housing Authority1002 Illinois Street

Hot Springs, AR 71901Telephone-501-624-4420/Fax-501-620-4272

APPLICATION FOR HOUSING ASSISTANCE

INSTRUCTIONS: Please read carefully.

1. This application is valid for all Public Housing properties operated by the Hot Springs Housing Authority.

2. To be qualified for housing assistance an applicant must:a) Be a family as defined in PHA’S Admission and Continued Occupancy policy; b) Meet the HUD requirements on citizenship or immigration status;c) Have an Annual Income at the time of admission that does not exceed the income limits

established by HUD that is posted in the PHA office;d) Provide documentation of Social Security numbers for all family members or certify that they

do not have Social Security numbers;e) Meet or exceed the Application Selection Criteria, including attending and successfully

completing a PHA-approved preoccupancy orientation session, if requested to do so;f) Pay any money owed to the PHA or any other Housing Authority;g) Not have had a lease terminated by the Housing Authority within the past 5 years;h) Be able and willing to comply with the Housing Authority Lease;i) Not have any family members engaged in any criminal activity that threatens the life, health,

safety, or right to peaceful enjoyment of the premises by other residents, and not have any family member engaged in any drug-related criminal activity.

3. THE COMPLETED APPLICATION WILL BE ENTERED ON THE WAIT LIST IN THE ORDER RECEIVED. The wait list will then be processed in order according to unit type, size and admission preferences.

4. THIS APPLICATION WILL BE ACCEPTED BY DROP-OFF OR BY MAIL sent to the following address, postmarked within dates when the Housing Authority is accepting applications:

Hot Springs Housing Authority P.O. Box 1257 Hot Springs, AR 719025. Each applicant who meets the above qualifications will be offered one unit of the size and type needed, unless there is good cause for unit refusal. If the applicant accepts the offer within 3 days, the

applicant will be offered a lease. If the applicant refuses the offer without good cause, the application will be withdrawn from the wait list and the applicant can reapply.

6. Applicants with disabilities may seek assistance with the completion of the application at the Housing Services Building located at 1002 Illinois Hot Springs, AR.

7. Be sure to include the name, social security number, date of birth and all income for every familymember who will live in the household. Be sure to provide copies of all necessary documentation in the Application for Housing Assistance check off list.

8. Be sure to provide your complete address and telephone number so we can reach you to schedule a briefing. You will be notified by mail.

Please have all applicants 18 and older initial that they have read the information supplied above:

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AN INCOMPLETE APPLICATION WILL NOT BE PROCESSED. BE SURE TO ANSWER ALL QUESTIONS.

____________ _____________ ____________ ____________Initials Initials Initials Initials

12-23-2013The Housing Authority is an Equal Housing Provider

APPLICATION FOR HOUSING ASSISTANCE CHECK OFF LIST

INSTRUCTIONS: Please read carefully.

Please make sure to include copies of all of the following documentation listed below for each family member who will live in the household:

Birth Certificate

Proof of Income (This may include a letter of confirmation, 3 current check stubs or other verifiable documentation for the following sources of earned income/benefits: AFDC/TANF, VA, Social Security, SSI, SSID, Unemployment, Worker’s Compensation, Child Support or other source)

Social Security Card (this may include a verifiable signed declaration pertaining to an Applicants Citizenship status)

Valid State or Federal Picture ID (adult household members only)

Please have all applicants 18 and older initial that they have provided copies of the information listed above:

____________ _____________ ____________ ____________Initials Initials Initials Initials

PHA USE ONLY:

Birth Certificate _____ _____ _____ _____ _____ _____ _____ _____ _____

Proof of Income _____ _____ _____ _____ _____ _____ _____ _____ _____

Social Security Card _____ _____ _____ _____ _____ _____ _____ _____ _____

Valid State or Federal Picture ID _____ _____ _____ _____ _____ _____ _____ _____ _____

PHA Staff: __________ __________

Initials Date

12-23-2013The Housing Authority is an Equal Housing Provider

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PHA use Only:Date of application:__________________ Time of Application:___________________

Head of Household ________________________________________________ Social Security Number ______________________________Last, First M.I.

Home Phone Number ___________________________________ Cell Phone Number ____________________________________________

MailingAddress__________________________________________PhysicalAddress______________________________________________

Personal DeclarationThis form must be completed in your own handwriting and in ink. You must use the correct legal name for each member of your household as it appears on the Social Security card. All adult members of the household must sign below certifying the information pertaining to them. Beginning with yourself, list all persons who will live in the PHA unit including foster children, live-in aides (if needed for the care of a family member). Each box must be completed for each family member. No one except those listed on this form may live in the unit. Please print.

Household Composition: List all persons who will be living in your home, listing Head of Household first.

Relationship ADULTS(LEGAL NAME) to Head Last Name (HEAD 1st) First Name M.I. Social Security Number Sex Disabled Person? Date of Birth Place of Birth

CHILDREN (Any person under the age of 18) Relationship Last Name First Name M.I. Social Security Number Sex Disabled Person Date of Birth Place of Birth Full Time Student Absent Parent Name

Absent Parents Name and Address:___________________________________________________________________________

Are you expecting a child? (Yes/No) If yes, what is the due date? _____________________________.

Is any other member of the household expecting a child? (Yes/No) Name of person expecting & due date:___________________________________________________.

If separated or divorced, list name and address of spouse/ex-spouse as follows:

__________________________________________ __________________________________________Name Name__________________________________________ __________________________________________

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Total Household Income: List all money earned or received by everyone living in your household. This includes money from wages, self-employment, child support, contributions from family members or friends, Social Security, disability payments (SSI), Workers Compensation, retirement benefits, TEA, veterans benefits, rental property income, stock dividends, interest income from bank accounts, alimony, and all other sources. List amounts receive below:

Employer’s Wages Frequency Address & Hr./week Hours Per Week/ Social

Household member Phone Number Pay Period Worked Month/Year Security TEA SSI Child Support All other income

Is any adult family member enrolled in a job-training program, including one required under the welfare program? Yes/No

Is any adult family member enrolled in an education program full-time? Yes/No

Assets:Checking Account#_____________________ Name and address of Institution______________________________________________ Balance as of today $__________

Savings Account# ______________________ Name and address of Institution _____________________________________________ Balance as of today$__________

Stocks, Bonds, Dividends, Certificates________________________________________________________________________

Do you own real estate? Yes/No Describe if answer is yes:_______________________________________________________

Expenses:Child Care Expenses: Yes/No If yes, please provide name of provider, address, and phone number _______________________________________________________________________________________________________

Cost per week _________________ Name of child or children in child care: _________________________________________

List an itemization of your monthly expenses:

Rent ____________ Car Payment __________ Utilities ______________ Furniture Payment/Rental ____________ Telephone ___________

Gas _____________ Credit Cards __________ Food ________________ Load Payments ____________________ Food Stamps ________

Cable TV_________ Diapers ______________ Paper products ________ Laundry/Cleaning __________________ Doctor ____________

Cigarettes ________ Prescriptions __________ Life Insurance _________ Fire Insurance _____________________ Burial Insurance _____

Car Repairs _______ Car Insurance _________ School Loans __________ Other ________________________

Does anyone outside of your household pay for any of your bills or give you money? Yes/No If yes, explain _____________________________________________________________________________________________________________________

Have you or any other adult member ever used any other name(s) or Social Security Number(s) other than the one you are

currently using? Yes/No __________________________________________________________________________________

If yes, explain___________________________________________________________________________________________

Have you or any member in your household lived in Public Housing or Section 8 anywhere in the U.S.? Yes/No __________

If yes, where and when?____________________________________________________________________________________

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Do you have any relatives living at the Hot Springs Housing Authority? Yes/No If yes, enter name and address of relative.

Name_________________________________________Address___________________________________________________

Name_________________________________________Address___________________________________________________

Name_________________________________________Address___________________________________________________

Have you or anyone in your household ever been arrested or convicted on any crime including any alcohol or drug related offenses?Do not include traffic violations. Yes/No ______. If yes, explain________________________________________________

Date family moved to this location:_____________________

Who are you presently living with?___________________________________________________________________________

List your addresses for the past five years:_____________________________________________________________________

A. What is your landlord’s name? ___________________________________Address ________________________________Phone Number_________________________

How long did you live there? From: __________________________ To ___________________________________

B. What is your landlord’s name? ___________________________________Address ________________________________Phone Number_________________________

How long did you live there? From: __________________________ To ___________________________________

C. What is your landlord’s name? ____________________________________Address ________________________________ Phone Number___________________

How long did you live there? From: __________________________ To ___________________________________

Have you ever been evicted or violated your rental lease? Yes/No __________ If yes, explain __________________________________________________________________________________________________________________________________

Have you ever had a judgment, garnishment or collection action levied against you? Yes/No If yes, explain________________

List two persons (relatives or friends) who could get in touch with you if we are unable to reach you.

(1) Name _________________________________Address _________________________________________Phone Number ____________________

(2) Name _________________________________Address _________________________________________ Phone Number ____________________

Do you have a car? Yes/No If so, Year ________ Make ________ Model_____________ License Plate # ____________

Driver’s License Number __________________

Do you have a state ID number? Yes/No If yes what is it? _________________________________________________

Public Housing or Section 8 balance:

Do you owe a balance to a public housing or Section 8 agency? Yes/No Amount$____________

Which Housing Authority? _______________________________

How long have you lived in Garland County?_______________________

How did you hear about the Housing Authority?__________________________________

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For Statistical Purposes Only

CIRCLE THE ANSWERS THAT APPLY: Race of Head: African American/ Black Asian or Pacific Islander Native American/ Alaskan Native Caucasian/ White Ethnicity of Head: Hispanic/ Latino Non-Hispanic/ Non-Latino

PHA will be contacting all former landlords for the period of five years from the date of application.

I/we certify that the statements on this application are true to the best of my/our knowledge and belief and understand that they will be verified. I/we authorize the release of information to the Hot Springs Housing Authority by my/our employer(s), the Department of Human Services, the Social Security Administration, and/or other business or government agencies. I/we understand that any false statement made on this application will cause me/us to be disqualified for admission.

Applicant Signature Date

Co-applicant Signature Date

Warning: 18 U.S.C. 1001 provides, among other things that whoever knowingly and willfully makes or uses a document or writing

containing false, fictitious or fraudulent statement or entry in any matter within the jurisdiction of a department or agency of the

United States shall be fined not more than 10,000.00 or imprisoned for not more than five years or both.

PUBLIC HOUSING VERIFICATION FORM

12-23-2013

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AUTHORIZATION FOR THE RELEASE OF INFORMATION

I have applied to (am housed with) the Hot Springs Housing Authority for federally assisted housing. The Housing Authority may use this authorization and the information obtained with it, to administer and enforce program rules and policies.

I authorize the release of any information including documentation and other materials pertinent to eligibility for or participation under the following programs:

Low Income Rental Public Housing Section 8 Housing Assistance Payments Program

Inquiries may be made about:

Child Care Expense Credit History Criminal Activity Family Composition Employment, Income, Pensions and Assets Federal, State, Tribal or Local Benefits Disability Assistance Expenses Identity and Marital Status Medical Expenses Social Security Numbers Residences and Rental History Utility Service Customer Status

I agree that photocopies of this authorization may be used for the purposes stated above.

I, therefore, respectfully request that you furnish to the Hot Springs Housing Authority any information requested and hereby release you from any and all liability of damages for providing such information.

Print Name of Applicant/Resident Signature of Applicant/Resident Date

Print Name of Spouse Signature of Spouse Date

Print Name of Other Adult Member Signature of Other Adult Member Date

Print Name of Other Adult Member Signature of Other Adult Member Date

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OMB Control # 2502-0581Exp. (11/30/2015)

Optional and Supplemental Contact Information for HUD-Assisted Housing Applicants

SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSINGThis form is to be provided to each applicant for federally assisted housing

Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing, the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update, remove, or change the information you provide on this form at any time. You are not required to provide this contact information, but if you choose to do so, please include the relevant information on this form.

Check this box if you choose not to provide the contact information.

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Telephone No: Cell Phone No:

Name of Additional Contact Person or Organization:

Address:

Telephone No: Cell Phone No:E-Mail Address (if applicable):

Relationship to Applicant:Reason for Contact: (Check all that apply)

EmergencyUnable to contact you Termination of rental

assistance Eviction from unitLate payment of rent

Assist with Recertification ProcessChange in lease termsChange in house rulesOther:

Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the issues or in providing any services or special care to you.

Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the applicant or applicable law.

Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992) requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or organization. By accepting the applicant’s application, the housing provider agrees to comply with the non-discrimination and equal opportunity requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on age discrimination under the Age Discrimination Act of 1975.

Signature of Applicant Date

The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520). The public reporting burden is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the obligation to require housing providers participating in HUD’s assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in the application for occupancy the name, address, telephone number, and other relevant information of a family member, friend, or person associated with a social, health, advocacy, or similar organization. The objective of providing such information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any delivery of services or special care to the tenant and assist with resolving any tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and maintained as confidential information. Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and management controls that prevent fraud, waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless the collection displays a currently valid OMB control number.Privacy Statement: Public Law 102-550, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be used by HUD to protect disbursement data from fraudulent actions.

Form HUD- 92006 (05/09

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CRIME REPORTHOT SPRINGS DISTRICT COURT

A CRIME REPORT HAS BEEN PERFORMED BY THEDISTRICT COURT FOR___________________________AT THIS TIME THERE IS NO RECORD OF ANY VIOLATIONS FOR THIS PERSON.

CLERK: __________________________________________________ DATE: _________________________

HOT SPRINGS HOUSING AUTHORITY

1002 ILLINOIS STREET/ PO BOX 1257HOT SPRINGS, AR 71902

501-624-4420 PH/ 501-623-8801 FAX