ࡱ> ` )bjbj L!8.6666FfFfFf8~f$fDDhh"iii k k k$hLń kj@ k k ḱ66ii&mmm kj6Riim kmmrwvT"wwih PNEFfskvw <Dv=l<wwwwd k km k k k k ḱ́ym^ k k kD k k k kD<DD"D666666 Sample Date: Dear Affordable Housing Applicant: Thank you for inquiring about affordable housing with [NAME ADMINISTRATIVE AGENT]. We currently administer [# OF AFFORDABLE HOUSING UNITS] throughout the [MUNICIPALITY/COUNTY/ETC]. However, we receive a greater number of applications than there are units available, so placement in a unit is often not immediate. In order to be eligible for an affordable housing unit, you must meet certain income limits as determined by the ԹϺ Council on Affordable Housing. Income limits are determined by region. Our housing units are located in [NAME OF REGION], which includes the following counties: [COUNTIES IN YOUR REGION]. Income limits can vary from year to year and depend upon the number of persons in the household. The income limits for [YEAR] are: Number of persons in householdMaximum Annual Income Very Low-Income UnitsMaximum Annual Income Low Income UnitsMaximum Annual Income Moderate Income Units12[MAXIMUM VERY[MAXIMUM LOW-[MAXIMUM3LOW-INCOMEINCOME LIMITSMODERATE-4LIMITS FORFOR YOUR INCOME LIMITS5YOUR REGION]REGION]FOR YOUR 6REGION]78 If you believe you fall within these income limits, fill out and submit this application for certification to our office. If certified, [Outline selection process (Example: you will be placed on our list of eligible buyers/rentsers. When a unit becomes available we randomize our list. If you are the first person selected, you will be invited to view the unit to see if you are interested. If you are not interested, we will go to the next person on the list, but when the next unit becomes available, our list is re-randomized, meaning that you will not receive preference for the next available unit. If the unit is for purchase, you will be required to obtain a mortgage.)] Also, you must provide all the applicable documentation listed on the attached checklist. We need this information to verify your income and household size. Please remember that all applications and documents are held in the strictest confidence. If you have any further questions please contact us at [PHONE NUMBER]. [Administrative Agent] APPLICATION FOR AFFORDABLE HOUSING APPLICANT NAME: ________________________ CURRENT ADDRESS: CITY, STATE, ZIPCODE: HOME PHONE: _____________WORK PHONE: OTHER: ______ HOUSEHOLD COMPOSITION AND CHARACTERISTICS List the Head of Household and all other members who will be living in the unit. Give the relationship of each family member to the head. #MEMBERS FULL NAMERELATIONBIRTH DATESEXSOCIAL SECURITY #1Applicant23456789 Does anyone live with you now who is not listed above: Yes No Do you expect a change in your household composition? Yes No Explain if you answered yes to either questions: ________________________________________________ Please identify any special housing needs. __________________________________________________________________ 5. Number of bedrooms requested based on family composition:_______________________ 6. Do you wish to rent or purchase or both? ____ rent _____ purchase _____either INCOME AND ASSET INFORMATION Please answer each of the following questions. For each yes, provide details in the charts below. Does any member of your household: YesNo1.Work full-time, part-time or seasonally?YesNo2.Expect to work for any period during the next year?YesNo3.Work for someone who pays you cash?YesNo4.Expect a leave of absence from work due to lay-off, medical, maternity or military leave?YesNo5.Now receive or expect to receive unemployment benefits?YesNo6.Now receive or expect to receive child support?YesNo7.Entitled to child support that he/she is not now receiving?YesNo8.Now receive or expect to receive alimony?YesNo9.Have an entitlement to receive alimony that is not currently being received?YesNo10.Now receive or expect to receive public assistance (welfare)?YesNo11.Now receive or expect to receive Social Security or disability benefits?YesNo12.Now receive or expect to receive income from a pension or annuity?YesNo13.Now receive or expect to receive regular contributions from organizations or from individuals not living in the unit?YesNo14.Receive income from assets including interest on checking or savings accounts, interest and dividends from certificates of deposit, stocks or bonds or income from rental property?YesNo15.Own real estate or any assets for which you receive no income (checking account, cash)?YesNo16.If you own a home, do you maintain a mortgage on the property? YesNo17.Have you sold or given away real property or other assets (including cash) in the past two years?YesNo18.Are you responsible for paying child support or alimony? This amount will be deducted from your total annual income. Amount Paid Monthly: $__________ MEMBER NO. SOURCE OF INCOME / TYPE OF INCOMETOTAL GROSS ANNUAL INCOME ASSETS List all checking and savings accounts (including IRAs, Keogh accounts, and Certificate of Deposit) of all household members. MEMBER NO. BANK NAMETYPE OF ACCOUNTACCOUNT NUMBERBALANCE List all stocks, bonds, trusts, pensions, or other assets, including a house, and their value, owned by any household member: List any assets disposed of for less than their fair market value during the past two years: PREVIOUS RENTAL HISTORY OR OWNERSHIP HISTORY Name and address of your Present Landlord or Current Address: Telephone: How long have you lived here? Reason for leaving? Name and address of your Former Landlord or Previous Address: Telephone: How long did you live there? Reason for leaving? EMPLOYMENT HISTORY Name and address of Head of Households present employment: Telephone: Supervisors Name? How long have you worked there? Name and address of spouses or co-head employer: Telephone: Supervisors Name? How long have you worked there? APPLICANT CERTIFICATION I/we certify that if selected to receive assistance, the unit I/we occupy will be my/our only residence. I/we understand that the above information is being collected to determine my/our eligibility. I/we authorize the owner/manager to verify all information provided on this application and to contact previous or current landlords or other sources of credit and verification information which may be released to appropriate Federal, State, or local agencies. I/we certify that the statements made in this application are true and complete to the best of my/our knowledge and belief. I/we understand that false statements or information are punishable under Federal Law. Signature of Head of Household _________ Date: ______ Signature of Spouse/Co-Head Date: ______ Signature of Administrative Agent ________________________________Date: ____________ We Do Business in Accordance With the Federal Fair Housing Law (The Fair Housing Amendments Act of 1988). It is Illegal to Discriminate Against Any Person Because of Race, Color, Religion, Sex, Handicap, Familial Status, or National Origin.  The following documentation (if it applies) must be provided so we can verify your income and household size. Personal identification (Drivers License, passport, birth certificate, social security card, etc.) Checking - 6 months of statements Savings Account (CD's, IRA's, etc) statements and current interest rates Bonds Stocks Real Estate (total value minus any outstanding mortgage balance, closing costs, broker's fees, etc) and income from real estate or businesses. 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