Fillable APPLICATION TO ADD NEW MEMBERS TO THE HOUSEHOLD (Housing Authority of the County of Santa Cruz)

Fill Online, Printable, Fillable, Blank APPLICATION TO ADD NEW MEMBERS TO THE HOUSEHOLD (Housing Authority of the County of Santa Cruz) Form

Use Fill to complete blank online HOUSING AUTHORITY OF THE COUNTY OF SANTA CRUZ pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

APPLICATION TO ADD NEW MEMBERS TO THE HOUSEHOLD (Housing Authority of the County of Santa Cruz)

On average this form takes 78 minutes to complete

The APPLICATION TO ADD NEW MEMBERS TO THE HOUSEHOLD (Housing Authority of the County of Santa Cruz) form is 9 pages long and contains:

  • 0 signatures
  • 89 check-boxes
  • 272 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Housing Authority of the County of Santa Cruz forms online.

BROWSE HOUSING AUTHORITY OF THE COUNTY OF SANTA CRUZ FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
050348 070212 JP 1
APPLICATION TO ADD NEW MEMBERS TO THE HOUSEHOLD
THE FOLLOWING INFORMATION IS REQUIRED TO DETERMINE POTENTIAL ELIGIBILITY FOR PROGRAM
PARTICIPATION OF ALL NEW HOUSEHOLD MEMBERS. COMPLETION OF THIS FORM DOES NOT GUARANTEE
ELIGIBILITY.
NEW HOUSEHOLD MEMBERS MAY NOT MOVE IN TO THE ASSISTED UNIT UNTIL YOU RECEIVE NOTIFICATION
FROM THE HOUSING AUTHORITY THAT APPROVAL HAS BEEN GRANTED.
Full Legal Name of Head of Household: __________________________________________ Tenant ID: ___________________
I. NEW MEMBERS REQUESTING TO BE ADDED TO THE HOUSEHOLD
List all persons, who you would like to add to your household. Attach additional sheets if necessary. Please note, the
remainder of the form requests income, asset, and expense information about these persons you are requesting to add.
A. Adults (age 18 or older)
Full Legal Name
as appears on Social Security Card
(Sample: Sue Ann Smith)
Date of Birth
(01/09/1970)
Job Title /
Occupation
(Nurse)
Relation to
Head of
Household*
(Spouse)
Social Security
Number
(123-45-6789)
Percent of
time adult
will live in
assisted unit
(100%)
/ /
%
/ /
%
/ /
%
/ /
%
B. Children (under 18 yrs)
Full Legal Name
as appears on Social Security Card
(Sample: John Matthew Smith)
Date of Birth
(07/02/1998)
Name / Address
of School or Pre-
School
(Harbor High,
Santa Cruz)
Relation to
Head of
Household
(Son)
Social Security
Number
(123-45-6789)
Percent of
time child
will live in
assisted unit
(100%)
/ /
- -
%
/ /
- -
%
/ /
- -
%
/ /
- -
%
* Please include a verification of the relationship between the head of household and the individual(s) you are requesting to add,
including birth certificate, marriage certificate, domestic partner registration, court / social service verification, or any other
applicable verification of each new member’s relationship to the head of household.
1. Has any potential new household member named above ever used any name(s) or social security number(s) other than the
one(s) provided above?
No Yes (If yes, please explain): ____________________________________________
050348 070212 JP 2
II. CRIMINAL HISTORY
Federal regulations require the Housing Authority to review the criminal background of all applicants, and prohibit admission to some applicants based on their
criminal history. THE HOUSING AUTHORITY WILL CONDUCT A CRIMINAL BACKGROUND CHECK ON ALL APPLICANTS TO VERIFY
THE ACCURACY OF THE INFORMATION PROVIDED BELOW AND TO COLLECT ANY ADDITIONAL INFORMATION DEEMED
NECESSARY BY THE HOUSING AUTHORITY. IF YOU LIE ON THIS FORM, OR IF YOU OMIT INFORMATION, YOUR APPLICATION FOR
ASSISTANCE WILL BE DENIED.
2. Has any potential new household member on this form ever been required to register as a sex offender?
No Yes – If yes, please explain, including name, date and disposition: ________________________________________________________________
3. Has any potential new household member on this form ever been evicted from federally assisted housing for drug-related offense in the past three years?
No Yes – If yes, please explain, including name, date and disposition: ________________________________________________________________
4. Has any potential new household member on this form ever been convicted of methamphetamine production or manufacturing?
No Yes – If yes, please explain, including name, date and disposition: ________________________________________________________________
5. Please provide the following information for any and all arrests of all potential new household members on this form. Attach additional sheets if necessary.
Full Legal Name
of Person Arrested
Description of
Crime
Type of Crime
(Violent, Drug,
Property, etc.)
Level of Crime
(Felony or
Misdemeanor)
(City, State,
County, Country)
Date of Crime
(Month, Year)
Did you serve any time in prison / jail
for the crime? (Y/N) If yes, where?
How long did you serve? When were
you released? (Month / Year)
The Housing Authority may need more information about your criminal history and / or current situation.
Please attach the names and contact information of any parole officer, counselor, or other character reference that could provide information about you.
Additionally, please provide copies of release paperwork, character reference letters from probation officers or counselors, copies of program completion
certificates, or any documentation that would help substantiate rehabilitation. If someone in the household has a criminal background, the Housing Authority
will evaluate all of the information we receive before we make a decision. Therefore, contact information of the individuals above, and / or release
paperwork, character reference letters and other documentation may influence whether your application is accepted or denied.
050348 070212 JP 3
III. HOUSEHOLD INCOME – ALL INCOME MUST BE REPORTED
A. Employment Income
6. Does ANY potential new household member on this form (age 18 or older) receive ANY of the following types of
Employment Related Income?
Yes No a. Employment Income (wages, salary, commissions, fees, tips, or bonuses)
Yes No b. Self-Employment Income (independent contractor, personal business, day labor, odd jobs, etc.)
Yes No c. Severance Pay (extra pay given to an employee upon termination of employment)
Yes No d. Pension / Retirement (from previous employment, excluding Social Security)
IF NO to all of the above, you may skip the table below and proceed to question 7.
IF YES to any of the above, use the space below to provide information about each person’s employment related
income. Report all current employment related income for every adult. If any adult has more than one job (or type of
employment related income), use additional rows as needed. If you don’t know your employer’s address, look at a
current pay stub. If self-employed, use the space below to provide information about your customers and clients.
Attach additional sheets if necessary.
Name of
Adult
Name of Employer / Address where
Employment can be Verified (If self-
employed, list customers / clients)
Phone Number
/ Fax Number
Type of Income
Gross
Amounts
Sample:
Sue
Main Hospital, 123 Main Street
City, State Zip Code
Phone: 555-1111
Fax: 555-2222
Employment
Self-Employment
Severance Pay
Pension / Retirement
Rate per hr:
$10.00
Hrs per week:
25
Phone:
Fax:
Employment
Self-Employment
Severance Pay
Pension / Retirement
Rate per hr:
____________
Hrs per week:
____________
Phone:
Fax:
Employment
Self-Employment
Severance Pay
Pension / Retirement
Rate per hr:
____________
Hrs per week:
____________
Phone:
Fax:
Employment
Self-Employment
Severance Pay
Pension / Retirement
Rate per hr:
____________
Hrs per week:
____________
B. Alimony / Spousal Support and Child Support
7. Does ANY potential new household member on this form receive, or have a court order to receive, alimony / spousal
support and / or child support / disregard for AFDC? Yes No
IF NO to the above, you may skip the table below and proceed to question 8.
IF YES to the above, use the space below to provide information about alimony and / or child support ordered and / or
received. Attach additional sheets if necessary.
Person
Receiving
Support
Name, Address, AND County of
Family Support Division or Other
Agency
Payee /
Participant
Number
Type of Support
Monthly
Amount
Ordered
Monthly
Amount
Received
Alimony / Spousal
Child Support
$________
$________
$_______
$_______
050348 070212 JP 4
C. Non-Employment Income
8. Does ANY potential new household member on this form receive Unemployment, Disability, Social Security,
Supplemental Security Income (SSI), Veterans Benefits, or Cash Aid / Welfare (including CalWORKS, AFDC –
Assistance to Families with Dependent Children, TANF – Temporary Assistance for Needy Families, GA – General
Assistance, or Kin Gap)?
Yes No
IF NO to the above, you may skip the table below and proceed to question 9.
IF YES to the above, list the GROSS amount of non-employment income each household member receives PER
MONTH from each of the income sources listed. Attach additional sheets if necessary. If a household member does
not receive one or more of the listed types of income, write “No” or “None” in the space provided.
Person
Receiving
Income
Unemployment
Development
Department (EDD)
Unemployment (UIB)
Employment
Development
Department (EDD)
Disability
Social Security
Benefits / SSB &
Supplemental
Security Income / SSI
Veterans
Benefits
Cash Aid / Welfare
(CalWORKS, AFDC,
TANF, GA, KinGap)
Sample: Sue None $685 None None $380
9. Does ANY potential new household member on this form receive Workers Compensation or payments for a Foster or
Adopted child
Yes No
IF NO to the above, you may skip the table below and proceed to question 10.
IF YES to the above, use the space below to provide information about each person’s Workers Compensation or
Foster / Adoption income. Attach additional sheets if necessary.
Person
Receiving
Income
Type of Income
Name, Address, and County of
Income Source
Monthly
Amount
Received
Workers Compensation Foster / Adoption
$_________
Workers Compensation Foster / Adoption
$_________
10. Does ANYONE outside of your household pay for any potential new household member’s bills or expenses, or give
any potential new household member money or any non-monetary contributions or gifts (such as groceries, products or
services)?
Yes No
IF NO to the above, you may skip the table below and proceed to question 11.
IF YES to the above, use the space below to provide information about contributions received. Attach additional
sheets if necessary.
Type of Contributions or
Gifts Received
Name / Address of Person or Agency who
Contributes
Phone
Number
Amount or
Value
How Often
050348 070212 JP 5
11. Does ANY potential new household member on this form receive ANY OTHER ASSISTANCE OR INCOME that
has not been reported on this form? Yes No
IF NO to the above, you may skip the lines below and proceed to question 12.
IF YES to the above, use the lines below to provide information about ANY other assistance or income received,
who receives the income, and the address where the income can be verified. Attach additional sheets if necessary.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
12. Are any current household members or any potential new household members on this form currently in the process of
applying for any additional sources of income such as Unemployment, Disability, Social Security, Supplemental
Security Income (SSI), Veterans Benefits, or Welfare (including AFDC, TANF, or General Assistance) or Workers
Compensation or Foster / Adoption Income?
Yes No (No one in the household is in the process of applying for any additional sources of income.)
IF NO to the above, you may skip the table below and proceed to question 13.
IF YES, use the space below to provide information about each person who is applying for additional income sources.
Person Applying for
Income
Type of Income Date Applied
Date Income is
Expected
Monthly
Amount
Expected
$_________
$_________
IV. ASSETS – ALL ASSETS MUST BE REPORTED
D. Bank Accounts
13. Does ANY potential new household member on this form have any accounts (checking, savings, or other) with a
financial institution? Yes No
IF NO to the above, you may skip the table below and proceed to question 14.
IF YES to the above, use the space below to provide account information. If more than one person is named on an
account, please list all account holders. List only one account on each line. Attach additional sheets if necessary.
Financial Institution / Bank Name
and Address
All Name(s) on
Account
Account
Number
Account Type
(Checking, Savings, Etc.)
Current
Balance
$_________
$_________
$_________
050348 070212 JP 6
E. Investment Accounts / Retirement Accounts / Real Estate Property
14. Does ANY potential new household member on this form have any of the following?
Certificates of Deposit Yes No Lottery Winnings Yes No
Savings Certificates Yes No Insurance Settlements Yes No
Money Market Funds Yes No Whole Life Insurance (with cash value) Yes No
Trust Funds Yes No Lump Sum Inheritance Yes No
Special Needs Trusts Yes No 401(k) Retirement (that you have access to) Yes No
Mobile Home Yes No Stocks Yes No
Land Yes No Bonds Yes No
House Yes No Cash (if yes, how much: $_________ ) Yes No
Independent Retirement Acct. (IRA) Yes No Self Employed Retirement (Keogh) Yes No
Personal Investments (jewels, coins) Yes No (if yes, list type: ______________________ value: ____________ )
IF NO TO ALL OF THE ABOVE, you may skip the table below and proceed to question 15.
IF YES TO ANY OF THE ABOVE, use the space below to provide the requested information. Attach additional
sheets if necessary.
Financial Institution / Bank Name and
Address Name(s) on Account
Account
Number
Account
Type
Estimated
Balance /
Value
$___________
$___________
15. Does ANY potential new household member on this form have ANY OTHER ASSET that has not been reported on
this form? Yes No
IF NO to the above, you may skip the lines below and proceed to question 16.
IF YES to the above, use the lines below to provide information about other assets. Attach additional sheets if
necessary.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
F. Disposal of Assets
16. In the past two years, has ANY potential new household member on this form sold or given away any type of asset
(such as money, bank accounts, house, land, mobile home, real estate property, investment accounts, retirement
accounts, life insurance policies, or any other assets)?
Yes No
IF NO to the above, you may skip the table below and proceed to question 17.
IF YES to the above, use the space below to provide the requested information. Attach additional sheets if
necessary.
Person who had Asset Type of Asset Sold or Given Away
Value when sold
or given away
Amount
Received
$______________
$_____________
$______________ $_____________
050348 070212 JP 7
V. ALLOWANCES
G. Child Care
17. Does ANY potential new household member on this form have expenses for childcare of a child aged 12 or younger to
allow a household member to work, look for work, or further his / her education (academic or vocational)?
Yes No
IF NO to the above, you may skip the table below and proceed to question 18.
IF YES to the above, use the space below to provide information about childcare expenses. Please list all agencies,
groups, and providers that you pay out of pocket child care expenses to. Do not include any costs that are reimbursed
from an outside agency or person. Attach additional sheets if necessary.
Name of
Child(ren)
Name of Adult who is able to
work, look for work, or go to
school because of this Childcare
Name and Address of Agency,
Group or Provider that you pay
for Child Care
Telephone
Number
Monthly
Cost to
Household
$________
$________
H. Medical Expenses and Disability Assistance Expenses
Based on your responses to the following questions, the Housing Authority may contact you for additional information
to determine whether or not you are eligible for any allowance.
18. Is ANY potential new household member on this form a person with disabilities (do not include temporary
disabilities)? Yes No
If yes to above, list name of person with disability:____________________________________________________
19. Does ANY potential new household member on this form currently have any unreimbursed (paid out-of-pocket)
medical expenses, including Medical insurance premiums? Yes No
If yes to the above, list name of person with unreimbursed medical expenses:________________________________
20. Do you anticipate any expenses in the next 12 months for care attendants or medical equipment for a household member
with disabilities, to allow that household member or another household member to work?
Yes No
I. Student Status
21. Is ANY potential new household member on this form (age 18 or older) enrolled in any classes at an institution of
higher education? Yes No
IF NO to the above, you may skip the table below and proceed to the Rental History Section below.
IF YES to the above, use the space below to provide information about student status. Attach additional sheets if
necessary.
Name of Student
Name of School
Student Status
Address of School
Full Time Part Time
Full Time Part Time
050348 070212 JP 8
VI. RENTAL HISTORY
Complete the following for each adult you would like to add to the household. Attach additional sheets if necessary.
Name of current landlord: Phone number:
Address of current landlord:
Current address of adult
requesting to be added: From: To:
Current phone number of adult
requesting to be added:
Name of previous landlord: Phone number:
Address of previous landlord:
Previous address of adult
requesting to be added: From: To:
Has ANY potential new household member on this form ever lived in public housing (property owned by a housing
authority) or federally subsidized housing? No Yes
IF NO to the above, you may skip the lines below and proceed to question 22.
IF YES to the above, complete the table below. Attach additional sheets if necessary.
Name at that time (if different)
Date(s) of occupancy
Address of unit
Name of owner / Housing Authority
Reason for leaving
22. Does ANY potential new household member on this form currently owe money to any housing authority or any other
agency that provides federally subsidized housing? No Yes
IF NO to the above, you may proceed to question 23.
IF YES to the above, please use the lines below to indicate who owes money, how much money is owed, who the
money is owed to, and why the money is owed:
_______________________________________________________________________________________
______________________________________________________________________________________________
23. Has ANY potential new household member on this form committed fraud or been requested to re-pay money for
knowingly misrepresenting information in a federally subsidized housing program? No Yes
IF NO to the above, you may proceed to the optional Special Needs section or to the Certifications section on the
following page.
IF YES to the above, please explain:___________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
______________________________________________________________________________________
050348 070212 JP 9
VII. SPECIAL NEEDS (OPTIONAL)
To help assess special housing needs, please indicate any specific features any potential new household member on this
form would require to accommodate a disability.
Wheelchair accessibility Ground floor unit No exterior stairs No interior stairs Grab bars
Lever faucets and / or door knobs Handrails Braille Accommodations for a seeing-eye dog
Indicator lights for those with impaired hearing Other:_______________________________________
(doorbell, smoke alarm, etc.)
VIII. CERTIFICATIONS
ALL ADULT HOUSEHOLD MEMBERS AGE 18 OR OLDER MUST READ AND PERSONALLY SIGN
THIS STATEMENT. NO ONE, INCLUDING PARENTS AND SPOUSES, MAY SIGN ON BEHALF OF
ANY ADULT.
1. I do hereby swear and attest that all of the listed information is true, complete, and correct.
2. I understand that false information or statements or omission of information are punishable under federal law.
3. I understand that false statements or false information are grounds for termination of housing assistance.
4. I understand the following items regarding changes to my household composition, income, and other information.
a. I understand that all new household members must be approved in writing by the Housing Authority prior to
moving in to the assisted unit.
b. I understand that I must report all changes in household income and assets in writing within 14 calendar days.
c. I understand that I must report all changes in address and telephone number in writing within 14 calendar days.
5. I understand that if I do any of the following, I may lose my rental assistance:
a. Fail to fulfill my obligations to submit my eligibility documents on time
b. Fail to attend or be on time for my recertification appointment(s), or any other Housing Authority appointment(s)
c. Fail to make my unit available for the annual Housing Quality Standards inspection at the appointed time
d. Fail to comply with any program responsibilities, including obligations listed on my voucher or in my lease.
e. Commit program fraud (for example not reporting income, unauthorized people in the unit, and any other type of
program fraud)
6. I understand that all members of my household are prohibited from any activity (including criminal activity and / or the
use of drugs or alcohol) that threatens the health, safety, or right to peaceful enjoyment of the premises by other
residents.
7. I understand that I will be required to repay all rental assistance overpaid on my household’s behalf due to fraud.
WARNING – TITLE 18 SECTION 1001 OF THE UNITED STATES CODE STATES THAT ANY PERSON WOULD
BE GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT
STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES.
ALL OF THE INFORMATION ON THIS FORM WILL BE INDEPENDENTLY VERIFIED BY THE HOUSING
AUTHORITY. IF YOU LIE OR OMIT INFORMATION, YOUR ASSISTANCE WILL BE TERMINATED AND
YOU WILL HAVE TO PAY BACK ALL ASSISTANCE OVERPAID DUE TO FRAUD.
x
Print Head of Household Name Signature of Head of Household Date
x
Print Name Signature of Other Adult
x
Print Name Signature of Other Adult
x
Print Name Signature of Other Adult
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

APPLICATION TO ADD NEW MEMBERS TO THE HOUSEHOLD (Housing Authority of the County of Santa Cruz)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 15 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document