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Adding an Adult to Your Household (Linn-Benton Housing Authority)

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Adding an Adult to Your Household
You must complete this packet and wait for the Housing Authority’s written approval before
anyone can
move in! With the exception of Live-in-Aids, LBHA will not approve a new adult
household member that is not the significant other or family member of the household.
After we receive your request, we will see if the person that you want to add meets eligibility
requirements.
Step 1. Head of Household Information
Your Name:
The Last Four Digits of Your Social Security Number:
Your Phone Number:
Step 2. Tell us about the person you want to add.
Their Name:
_____ Relationship to you? ______________
Have they ever used another name? Yes No If yes, what?
I do hereby agree to the addition of the above family member and acknowledge that once added to
the household, the above family member will have equal rights to the voucher in cases of family
break up.
Signature of Head of Household: _______________________________ Date: ________________
Step 3. Have the person you want to add complete the packet.
Did the person you are adding complete the Attached Forms? Yes No
Did they attach a copy of their Social Security Card and photo ID? Yes No
Did you supply verification of their income (if applicable)? Yes No
Did you supply verification of their assets (if applicable)? Yes No
Step 4. Landlord Approval
To be completed by the landlord: PLEASE CHECK YES OR NO
I understand that my current tenant is asking my permission to add the above-named person to their
household:
YES, I do agree to allow the above named person to be added to the household pending Housing Authority approval.
NO, I do not give permission for the above named person to occupy the rental unit.
Printed Name of Landlord:_________________________________________ Phone Number:________________
Signature of Landlord:____________________________________________ Date:________________________
Step 5. Return the completed packet to the Housing Authority and wait to hear from us. You
should
receive a letter in approximately one week.
Remember, you must wait for approval before anyone can move in.
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PRELIMINARY STATEMENT OF ELIGIBILITY
This form is to be completed by the person who wishes to be added to an existing Section 8 lease.
Please complete in your own handwriting. Do not use a pencil. Please use an ink pen.
Full Legal Name of
Head of Household:
Full Legal Name of
Person to be Added to Household:
The following information should be for the person being added to the voucher.
Disabled: Yes No
Social Security No.:
Race: White Black/African American
American Indian/Alaska Native
Asian
Native Hawaiian/Other Pacific Islander
Ethnicity:
Hispanic/Latino
Non-Hispanic/Non-Latino
Date of Birth:
Sex:
Male
Female
What language do you speak?
English Spanish Other ____________
Present Address:
Street::
Zip Code:
Mailing Address:
Street::
Zip Code:
Home/Cell
Phone:
Work
Phone:
Message
Phone:
Please list all sources of income: (must provide verification)
Source of Income
Monthly Amount
Name and Full Address of Employer(s)
Please list all assets: (must provide verification)
Type of Asset
Account Balance
Name and Full Address of Bank or Institution
Savings
Checking
Other:
Program Integrity Information
Do you owe money to any office for previous participation in a housing program? ..................... Yes No
Have you ever committed fraud in connection with any federal assisted housing program?....... Yes No
Have you ever been arrested for, charged with or convicted of drug related criminal activity?.... Yes No
Have you ever been arrested for, charged with or convicted of violent criminal activity?............. Yes No
Are you required to register as a sex offender?............................................................................ Yes No
Please explain any “Yes” answers above:
_______
Certification of Person to be Added to Household:
I do hereby swear and attest that all of the information reported on this form about my family and me is true and
correct. I
understand that the Housing Authority is required to verify the information that I have reported. I understand
that any
misrepresentation of information or failure to disclose information requested may be grounds for
termination of assistance
and is punishable under Federal law.
Signature of Addition:__________________________________________ Date:_______________
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3/9/2016 C:\Forms\Declaration of Immigration Status 1
THIS FORM MUST BE COMPLETED
Declaration of Immigration Status
All adults, 18 years of age or older, must sign their own declaration. For children under 18 years of age,
the declaration must be signed by the parent or legal guardian residing (or who will reside) in the unit
and is responsible for the minor.
PROPOSED ADDITION #1:
Under Penalty of Perjury, I declare that:
Proposed Addition #1’s Name
IS: a citizen of the United States
a non-citizen with eligible immigration status. I understand that I must provide
documentation of eligible status for the family member listed above.
choosing not to certify that he or she is a citizen or has eligible immigration status. I
understand that this may effect the amount of housing assistance that my family will receive.
a non-citizen without eligible immigration status.
CERTIFIED BY:
Adult’s Signature Date
PROPOSED ADDITION #2:
Under Penalty of Perjury, I declare that:
Proposed Addition #2’s Name
IS: a citizen of the United States
a non-citizen with eligible immigration status. I understand that I must provide
documentation of eligible status for the family member listed above.
choosing not to certify that he or she is a citizen or has eligible immigration status. I
understand that this may effect the amount of housing assistance that my family will receive.
a non-citizen without eligible immigration status.
CERTIFIED BY:
Adult’s Signature Date
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11/2015 Section 8 Family Obligations
Section 8 Family Obligations
24CFR 982.551
Department of Housing and Urban Development regulations for the Housing Choice Voucher Program permits
LBHA to terminate assistance to participants in these programs if any household members or guests do not
abide by the following family obligations once the unit is approved and the HAP contract has been executed.
1) The Family MUST:
a) Supply any information that LBHA or HUD determines to be necessary including evidence of citizenship
or eligible immigration status, and information for use in regularly scheduled re-examination or interim
re-examination of family income, composition and criminal history. You must keep appointments as
they are scheduled, complete paperwork, return forms, and sign documents by the deadline imposed
by the Housing Authority staff. Provide current, reliable mailing address if different from assisted
dwelling to help ensure receipt of HA correspondence. Two missed appointments to supply LBHA with
this information is considered a breach of a family responsibility. New income for all family members
must be reported in writing within 10 days of the change (such as hire date of new job - not first
paycheck.) New income includes, but is not limited to: Wages, Unemployment, Child support, TANF,
Social Security, Pensions, and any other source of income (whether it’s expected to continue or not.)
b) Disclose and verify social security numbers and sign and submit consent forms for obtaining
information.
c) Supply any information requested by LBHA to verify that the family is living in the unit or information
related to family absence from the unit.
d) Notify LBHA in writing within 10 days if any family member no longer lives in the unit.
e) Notify LBHA in writing within 10 days when the family or a family member is away from the unit for an
extended period of time (10 days or more) in accordance with LBHA policies.
f) Notify LBHA and the owner in writing before moving out of the unit or terminating the lease.
g) Allow LBHA to inspect the unit at reasonable times and after reasonable notice. Two missed
appointments for inspection are considered a breach of this family responsibility.
h) Use the assisted unit for residence by the family. The unit must be the family’s only residence.
i) Notify LBHA in writing within 10 days of the birth, adoption, or court-awarded custody of a child.
j) Request LBHA written approval to add any other family member as an occupant of the unit (should
receive landlord’s permission first). Additional family members must not move in to the unit until
approved by the Housing Authority.
k) Give LBHA a copy of all notices including any owner eviction notice within 10 days of receipt.
l) Pay utility bills and supply appliances that the owner is not required to supply under the lease.
m) You may have guests, but such guests may not occupy the premises for more than 30 consecutive
days or more than 90 non-consecutive days in any 12-month period. You may not have any series of
guests who exceed these limits without our approval. The assistance you receive is for your immediate
family, not for your friends and relatives. A guest is considered to occupy the unit if they conduct
normal daily functions in the assisted unit (such as: bathing, eating, sleeping, storing clothing or other
personal belongings, etc.). Must get HA approval prior to allowing additional family member/s to
move in.
11/2015 Section 8 Family Obligations
2) The Family (Including Each Family Member) Must NOT:
a) Own or have any interest in the unit (other than in a cooperative, or the owner of a manufactured
home leasing a manufactured home space).
b) Commit any serious or repeated violations of the lease. (IE: non-payment or late payment of rent,
poor housekeeping, disturbing the peaceful enjoyment of neighbors etc.)
c) Commit fraud, or bribery or any other corrupt or criminal act in connection with the program.
d) Participate in illegal drug or violent criminal activity. The family is responsible for the illegal drug or
violent criminal activity of guests in the assisted unit.
e) Sublease or let the unit or assign the lease or transfer the unit.
f) Receive Housing Choice Programs tenant-based housing assistance while receiving another housing
subsidy, for the same unit or a different unit under any other Federal, State or Local housing
assistance program.
g) Damage the unit or premises (other than damage from ordinary wear and tear) or permit any guest to
damage the unit or premises.
h) Engage in threatening, abusive or violent behavior toward any LBHA personnel.
i) Be related to the landlord (owner). The landlord cannot be the parent, child, grandparent,
grandchild, sister or brother of any member of the participating family, including minors. The only
exemption that may be approved by LBHA is if a family member is a person with disabilities.
j) Engage in illegal use of a controlled substance; or abuse of alcohol that threatens the health and
safety or right to peaceful enjoyment of the premises by other residents.
k) Breach an agreement with LBHA to pay amounts owed to the Housing Authority.
Any information the family supplies must be true and complete.
By its signature, the family agrees to fulfill the program responsibilities noted above, and understands that failure to
do so, BY ANY FAMILY MEMBER, may result in permanent loss of housing assistance eligibility, and criminal
prosecution.
Signatures (EVERYONE 18 AND OLDER MUST SIGN):
1. Date:
2. Date:
3. Date:
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Original is retained by the requesting organization.
form HUD-9886
(07/14)
ref. Handbooks 7420.7, 7420.8, & 7465.1
Authorization for the Release of Information/
Privacy Act Notice
to the U.S. Department of Housing and Urban Development (HUD) OMB CONTROL NUMBER: 2501-0014
and the Housing Agency/Authority (HA) exp. 07/31/2017
Persons who apply for or receive assistance under the following
programs are required to sign this consent form:
PHA-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 consent
form may result in the denial of eligibility or termination of
assisted housing benefits, or both. Denial of eligibility or termi-
nation of benefits is subject to the HA’s grievance procedures and
Section 8 informal hearing procedures.
Sources of Information To Be Obtained
State Wage Information Collection Agencies. (This consent is
limited to wages and unemployment compensation I have re-
ceived during period(s) within the last 5 years when I have
received assisted housing benefits.)
U.S. Social Security Administration (HUD only) (This consent is
limited 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 is
limited to unearned income [i.e., interest and dividends].)
Information may also be obtained directly from: (a) current and
former employers concerning salary and wages and (b) financial
institutions concerning unearned income (i.e., interest and divi-
dends). I understand that income information obtained from these
sources will be used to verify information that I provide in
determining eligibility for assisted housing programs and the level
of benefits. Therefore, this consent form only authorizes release
directly from employers and financial institutions of information
regarding any period(s) within the last 5 years when I have
received assisted housing benefits.
Authority: Section 904 of the Stewart B. McKinney Homeless
Assistance Amendments Act of 1988, as amended by Section 903
of the Housing and Community Development Act of 1992 and
Section 3003 of the Omnibus Budget Reconciliation Act of 1993.
This law is found at 42 U.S.C. 3544.
This law requires that you sign a consent form authorizing: (1)
HUD 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 for
keeping that information; (3) HUD to request certain tax return
information from the U.S. Social Security Administration and the
U.S. Internal Revenue Service. The law also requires independent
verification of income information. Therefore, HUD or the HA
may 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 the
sources listed on the form. HUD and the HA need this information
to 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 computer
matching programs with these sources in order to verify your
eligibility and level of benefits.
Uses of Information to be Obtained: HUD is required to protect
the income information it obtains in accordance with the Privacy
Act 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 HAs
for the purpose of determining housing assistance. The HA is also
required to protect the income information it obtains in accordance
with any applicable State privacy law. HUD and HA employees
may 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 your
household who is 18 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 18 years of age.
PHA requesting release of information; (Cross out space if none) IHA requesting release of information: (Cross out space if none)
(Full address, name of contact person, and date) (Full address, name of contact person, and date)
U.S. Department of Housing
and Urban Development
Office of Public and Indian Housing
Linn-Benton Housing Authority
1250 Queen Ave SE
Albany, OR 97322
Phone: (541) 926-4497
Fax: (541) 926-3589
Original is retained by the requesting organization.
form HUD-9886
(07/14)
ref. Handbooks 7420.7, 7420.8, & 7465.1
Signatures:
_____________________________________________ ______________
Head of Household Date
___________________________________________
Social Security Number (if any) of Head of Household
__________________________________________________ _______________
Spouse Date
__________________________________________________ _______________
Other Family Member over age 18 Date
__________________________________________________ _______________
Other Family Member over age 18 Date
Consent: I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form for
the purpose of verifying my eligibility and level of benefits under HUD’s assisted housing programs. I understand that HAs that
receive income information under this consent form cannot use it to deny, reduce or terminate assistance without first
independently verifying what the amount was, whether I actually had access to the funds and when the funds were received. In
addition, I must be given an opportunity to contest those determinations.
This consent form expires 15 months after signed.
__________________________________________________ ________________
Other Family Member over age 18 Date
__________________________________________________ ________________
Other Family Member over age 18 Date
__________________________________________________ ________________
Other Family Member over age 18 Date
__________________________________________________ ________________
Other Family Member over age 18 Date
Penalties for Misusing this Consent:
HUD, the HA and any owner (or any employee of HUD, the HA or the owner) may be subject to penalties for unauthorized disclosures or improper uses of
information collected based on the consent form.
Use 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 willfully
requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more
than $5,000.
Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, against
the officer or employee of HUD, the HA or the owner responsible for the unauthorized disclosure or improper use.
Privacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this information
by the U.S. Housing Act of 1937 (42 U.S.C. 1437 et. seq.), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and by the Fair
Housing Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants and
participants 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 monitoring
HUD-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 permitted
or 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. Giving the Social Security Numbers of all household members
six 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.
03/09/16 Release Of Information
Authorization for Release of Information
Purpose: The Linn-Benton Housing Authority uses this authorization and the information obtained with it to administer and
enforce housing program rules and policies.
Individuals or Organizations requested to release information: Any of the following individuals or organizations
including any governmental organizations may be asked to release information.
° Employers, Past & Present
° Banks, Credit Unions and Other Financial Institutions
° State Agencies such as CAF (Welfare) & Social Services
° Providers of Alimony, Child Care, Child Support, Credit, Handicapped Assistance, Medical Care,
Pensions/Annuities, Retirement Systems, Mental Health Care, Drug & Alcohol Rehabilitation Programs
° Social Security Administration
° Department of Veterans Affairs
° Schools and Colleges
° Courts & Law Enforcement Agencies
° Post Offices
° Utility Companies
° Credit Bureaus, Credit Providers
° Current & Previous Landlords (including Public Housing Agencies)
° Professional Personal References
° Other:
Information Covered - The information shared may include:
° Child Care Expenses ° Handicapped Assistance Expenses
° Credit History, Financial Concerns ° Criminal Activity, Legal Issues
° Identity and Marital Status ° Household Composition
° Social Security Numbers ° Residences & Rental History
° Federal, State, Tribal or Local Benefits
° Employment, Income, Pensions, and Assets
° Medical, Psychological or Psychiatric Issues & Expenses
Authorization
● I authorize the release of any information (including documentation and other materials) pertinent to eligibility for or
participation in the Section 8 Assistance Programs and any other Housing Assistance programs administered by the Linn-
Benton Housing Authority.
● I understand that this authorization can not be used to obtain any information about me that is not pertinent to my eligibility
for and continued participation in the Section 8 Assistance Program and any other Housing Assistance programs
administered by the Linn-Benton Housing Authority.
● I agree that photocopies of this authorization may be used for the purposes stated above.
● I authorize the release of information for minor children in the household to obtain wage information and criminal records.
This consent form expires 15 months after signed.
1.
Print Name Signature
Last 4 digits of Social Security number Date of Signing
2.
Print Name Signature
Last 4 digits of Social Security number Date of Signing
All household members 18 years of age and older must sign this form.
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Paperwork Reduction Notice: Public reporting burden for this collection of information is estimated to average 7 minutes
per response. This includes the time for respondents to read the document and certify, and any recordkeeping burden. This
information will be used in the processing of a tenancy. Response to this request for information is required to receive
benefits. The agency may not collect this information, and you are not required to complete this form, unless it displays
a currently valid OMB control number. The OMB Number is 2577‐0266, and expires 08/31/2016.
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 Public
Housing Agencies (PHAs) or Section 8 landlords and adverse information of former participants who have voluntarily or
involuntarily terminated participation in one of the above-listed HUD rental assistance programs. This information is
maintained 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, to
reduce administrative and rental assistance payment errors. The EIV system is designed to assist PHAs and HUD in
ensuring that families are eligible to participate in HUD rental assistance programs and determining the correct
amount of rental assistance a family is eligible for. All PHAs are required to use this system in accordance with HUD
regulations at 24 CFR 5.233.
HUD requires PHAs, which administers the above-listed rental housing programs, to report certain information at the
conclusion of your participation in a HUD rental assistance program. This notice provides you with information on what
information the PHA is required to provide HUD, who will have access to this information, how this information is used
and your rights. PHAs are required to provide this notice to all applicants and program participants and you are
required 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 of
birth, and Social Security Number.
The following adverse information is collected once your participation in the housing program has ended, whether you
voluntarily 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 charges
such 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; and
3. Whether or not you have defaulted on a repayment agreement; and
4. Whether or not the PHA has obtained a judgment against you; and
5. Whether or not you have filed for bankruptcy; and
6. 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.
U.S. Department of Housing and Urban Development
Office of Public and Indian Housing
DEBTS OWED TO PUBLIC HOUSING AGENCIES AND TERMINATIONS
OMB No. 2577-0266 Expires 08/31/2016
08/2013
Form HUD-52675
2
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 of
family income and composition for existing participants. PHAs will be able to access this information to determine a
family’s suitability for initial or continued rental assistance, and avoid providing limited Federal housing assistance to
families who have previously been unable to comply with HUD program requirements. If the reported information is
accurate, a PHA may terminate your current rental assistance and deny your future request for HUD rental assistance,
subject to PHA policy.
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 of
participation date.
What are my rights?
In accordance with the Federal Privacy Act of 1974, as amended (5 USC 552a) and HUD regulations pertaining to its
implementation 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, subject to 24 CFR Part 16.
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 upon receipt of your written and signed request.
What do I do if I dispute the debt or termination information reported about me?
If you disagree with the reported information, you should contact in writing the PHA who has reported this information
about you. 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 the
information and provide any documentation that supports your dispute. HUD's record retention policies at 24 CFR Part 908
and 24 CFR Part 982 provide that the PHA may destroy your records three years from the date your participation in the
program ends. To ensure the availability of your records, disputes of the original debt or termination information must be
made within three years from the end of participation date; otherwise the debt and termination information will be
presumed correct. Only the PHA 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 the
bankruptcy court, your record will be updated to include the bankruptcy indicator, when you provide the PHA with
documentation 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 PHA
determines that the disputed information is correct, the PHA will provide an explanation as to why the information is
correct.
T
his Notice was provided by the below-listed PHA:
I hereby acknowledge that the PHA provided me with the
Debts Owed to PHAs & Termination Notice:
Signature Date
Printed Name
OMB No. 2577-0266 Expires 08/31/2016
08/2013
Form HUD-52675
LINN-BENTON HOUSING AUTHORITY
1250 QUEEN AVE SE
ALBANY, OR 97322
(541) 926-4497
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Adding an Adult to Your Household (Linn-Benton Housing Authority)

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Completed 9 October 2020

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