Fillable Dear Prospective Applicant, Thank you for your interest

Fill Online, Printable, Fillable, Blank Dear Prospective Applicant, Thank you for your interest Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Dear Prospective Applicant, Thank you for your interest

On average this form takes 11 minutes to complete

The Dear Prospective Applicant, Thank you for your interest form is 25 pages long and contains:

  • 1 signature
  • 10 check-boxes
  • 35 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS 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
 
Dear Prospective Applicant,
Thank you for your interest in applying for an apartment at Casa de la Vista. Casa de la Vista
provides housing for senior households whose Head of Household, Spouse or Co-Head is 62 years
of age or older at time of application or for 10% of units which are handicap accessible, persons
(elderly or non-elderly) who require the accessible features of the unit. Additionally, the total
annual income of the household must fall under the maximum income limit for the community, as
determined by HUD. All information requested in the application packet must be completed.
Incomplete applications will not be considered. If the information requested does not apply to you,
please indicate by using “N/A” for not applicable. This will tell us that you understand the
requested information and you did not intentionally leave it blank.
If you make a mistake or typo,
please draw a single line through the error(s) and initial the change(s). Please do not use
whiteout to correct the errors.
Please check that you have completed, signed, and returned the following forms:
o Application for Housing
o HUD Section 214 Tenant Summary Form
o HUD Section 214 Declaration Form (complete one form for each household member)
o HUD-92006 Emergency Contact Information Form
o HUD-27061-H Race and Ethnicity Data Form (complete one form for each household
member)
Once the application is received, it will be determined whether you preliminarily qualify to be
placed on the waiting list. If you do not qualify, you will be notified in writing. Please remember
to notify us, in writing, if your information changes (contact information, income information,
etc.). We update our waiting list once per year. If you don’t respond to us whether or not you still
want your name to remain on the waiting list, you will be removed from our waiting list.
The apartments are offered as they become available. As your name reaches the top of the waiting
list, you will be required to come in for an interview. At that time, you will be asked to sign the
authorization forms which allows our staff to further verify your age, income, assets, allowances,
criminal history, sex offender status, credit history and landlord references.
Should you require a reasonable accommodation based on a disability to afford you an equal
opportunity to participate in this housing opportunity, please contact the management office at the
address below or phone/TDD so that we can consider your request for reasonable accommodation.
Sincerely,
Casa de la Vista Community Management
Page 1 of 6 v. 05/2018
686 E. Redlands Blvd.
Redlands, CA 92373
Phone (909) 335-8888, Fax (909) 335-8890
TDD (800) 545-1833 ext. 478
E-mail: CDV-Administrator@HumanGood.org Updated Application
Web: www.HumanGood.org (office use only)
APPLICATION FOR HOUSING
Part I. Applicant (Head of Household)/Co-applicant Information
Part II. General Questionnaire
1. Have you or any adult member of your household ever been evicted? Yes No If yes, when? Explain.
2. Have you or any adult member of your household ever been convicted of a misdemeanor or felony? Yes No
If yes, when? Explain.
3. Are you or any adult member of your household required to register as a sex offender including who is subject to a lifetime sex
offender registration requirement in any state? Yes No
If yes, list state and county of registration:
4. Do you or any adult member of your household currently use any illegal drug or other illegal controlled substance?
Yes No If yes, please explain:
__________________________________________________________________________________________________________
5. Do you expect changes to your household size within the next 12 months? Yes No If yes, please provide name.
__________________________________________________________________________________________________________
APPLICANT (HEAD OF HOUSEHOLD)
First Name: Middle Initial: Last Name:
Present Address: City: State: Zip Code:
Mailing Address (if different): City: State: Zip Code:
________________________________________________________________________________________________________
Home Phone: Work Phone: Cell Phone:
( )_______________________ ( )_______________________ ( )___________________________
Social Security #: _____________________________ Date of Birth: ___________________________________
Email Address: _________________________________________________________
Sex: F M Prefer not to disclose
CO-APPLICANT
First Name: Middle Initial: Last Name:
Social Security #: ____________________________________
Date of Birth: _____________________________
Relationship to Applicant: ________________________________ Cell Phone: ______________________________
Email Address: ___________________________________________________________
Sex: F M Prefer not to disclose
For Office Use Only
Date/Time Received:
Application/Wait List #:
__________________________
Page 2 of 6 v. 05/2018
Part III. Housing References – Please list current and previous landlords for the last five years.
6. Is there a live-in aide who will be residing with you in the unit? Yes
No
If yes, please provide name.
__________________________________________________________________________________________________________
7.
H
ow did you hear about this housing opportunity?
8. Do you have any animals? Yes No If yes, please list:
_________________________________________________________________________________________________________
9.
D
o you own a car? Yes No If yes, please list:
________________________________________________________________________________________
10. Are you an U.S. military veteran? Yes No
Which Branch? Air Force Army Coast Guard Marines Navy
Address of Present Residence:
Present Landlord Name: Landlord Telephone: Fax:
( ) ( )
Present Landlord Mailing Address: City, State: Zip Code:
Monthly rent: # of bedrooms: Is your rent subsidized? Rent Own
$ 1 2 3 4 5 YES NO
How long have you lived at this address? Reason for wanting to move?
________Years ________Months
Is there anyone living with you now that will not be moving with you to this property? YES NO If yes, who? And why?
I
f you have lived at your current address less than five years, what was your previous address?
Previous Address:
Name of previous Landlord: Landlord Telephone: Fax:
( ) ( )
Previous Landlord Mailing Address: City, State: Zip Code:
Monthly rent: How long have you lived at this address? Reason for moving?
$ ________Years ________Months
I
f you lived in the above two housing situations for less that 5 years, where did you live?
Previous Address:
Name of previous Landlord: Landlord Telephone: Fax:
( ) ( )
Previous Landlord Mailing Address: City, State: Zip Code:
Monthly rent: How long have you lived at this address? Reason for moving?
$ _______Years ________Months
L
ist all states in which all household members have resided since age 18:
______________________________________________________________________
Page 3 of 6 v. 05/2018
Part IV. Income Information
Current Income (Employment Sources)
List all full and/or part-time employment income for all household members.
(Include self-employment gross earnings and net taxable earnings)
Full Name Occupation Name/Address of Employer Length of Gross Earnings BEFORE Taxes
Employment
1. __________________________ Monthly: $ ______________
__________________________ Hours per week: __________
__________________________ Hourly rate: $____________
Full Name Occupation Name/Address of Employer Length of Gross Earnings BEFORE Taxes
Employment
2. __________________________ Monthly: $ _______________
__________________________ Hours per week: ___________
__________________________ Hourly rate: $_____________
Full Name Occupation Name/Address of Employer Length of Gross Earnings BEFORE Taxes
Employment
3. __________________________ Monthly: $ ______________
__________________________ Hours per week: __________
__________________________ Hourly rate: $____________
Full Name Occupation Name/Address of Employer Length of Gross Earnings BEFORE Taxes
Employment
4. __________________________ Monthly: $ ______________
__________________________ Hours per week: __________
__________________________ Hourly rate: $____________
Other Sources of Income
(examples: list all public assistance, social security, S.S.I., pension, retirement, disability compensation,
unemployment compensation, veterans benefits, insurance policies, interest income, babysitting, care-
taking allowance, alimony, child support, annuities, trusts, dividends, regular contributions, scholarships,
grants, armed forces)
Full Name Type of Income Amount
$ Per
Full Name Type of Income Amount
$ Per
Full Name Type of Income Amount
$ Per
Full Name Type of Income Amount
$ Per
Page 4 of 6 v. 05/2018
Part V. Asset Information
Part VI. Program Information
1. Are you or any member of your household disabled? Yes
No
________________________________________________________________________________________________________
2. Do you require a unit with accessible features for persons with disabilities? Yes No If yes, what features:
______ Mobility Impairment ______ Visual Impairment ______ Hearing Impairment ______ Other
3. Do you require a reasonable accommodation due to a disability that requires changes to our rules, policies, procedure or physical
modification(s) to the dwelling unit or common areas? Yes No If yes, please describe your needs:
__________________________________________________________________________________________________________
4. Do you currently hold a Section 8 voucher? Yes No If so from what county?
__________________________________________________________________________________________________________
Assets –
include checking and savings accounts, equity in real property, stocks, bonds, and other forms of
capital investment. Do not include automobiles or furniture. If you have no assets, write “none” in the space.
Checking Account – Name of Bank Savings account – Name of Bank
Address: Address:
Account Number: Account Number:
Cash Value /Balance: Cash Value /Balance:
$ $
Other Account – Name of Bank Other Account – Name of Bank
Address: Address:
Account Number: Account Number:
Cash Value /Balance: Cash Value /Balance:
$ $
401K/403B/IRA Other Account – Name of Bank
Address: Address:
Account Number: Account Number:
Cash Value /Balance: Cash Value /Balance:
$ $
Stocks and Bonds Value: Savings Bond Value:
$ $
Do you own Real Estate or Real Property? If yes, where? What is the current value?
Yes No
Have you ever owned Real Estate or Real Property? If yes, when? Where? When Sold? How Much?
Yes No
Have you or any adult member of your household disposed of any assets within the last 2 years for less than fair market
value? Yes No If yes, what was disposed and for how much?
__________________________________________________________________________________________________________
Page 5 of 6 v. 05/2018
Part VII. Allowances
Yes No
Do you have any out-of-pocket childcare expenses? If yes, how much do you pay per month? $____________
Are there any household members over the age of 18 that is a student? If yes, please list:
N
ame ______________________ PT FT Name _____________________ PT FT
Are you covered by any medical insurance? If yes, how much are your monthly premiums? $______________
ο
Medi-Cal ο Medicare ο Blue Cross ο Kaiser ο AARP ο Other _____________
Do you or any household member have any medical expenses including prescription drug, vision and dental expenses
not covered by insurance? If yes, how much do you anticipate paying out-of-pocket per month? $___________
Do you have any anticipated medical expenses that are NOT covered by insurance? If yes, How much per month?
$__________
Do you anticipate any major dental, vision, or hearing-aid expenses in the coming year that are not covered by
insurance? If yes, how much do you anticipate spending out of pocket next year? $_____________
If you or your co-head or spouse is employed, do you anticipate expenses in the COMING year, for the cost of a care
attendant for you or your spouse as a handicapped or disabled person as defined by HUD? (If yes proof of actual
expenses are required) If yes, How much do anticipate out-of-pocket per month? $____________
I understand that Casa de la Vista is a Non-Smoking Community. I understand that smoking is only permitted in
designated areas. Yes [ ] No [ ]
Page 6 of 6 v. 05/2018
I/We certify the above information to be true and correct to the best of my/our knowledge. I/We authorize
verification of age, income, assets, allowances, credit history, rental history, criminal background, registered
sex offender status, eviction and landlord references. I/We understand that falsification of information found
before or after acceptance of this property includes penalties that will result in cancellation of your application,
also to include eviction, loss of assistance, if applicable. If this is a HUD subsidized property, the additional
fines are imposed: fines of $10,000.00 and five years imprisonment.
WARNING!: Title 18, Section 1001 of the
United States Code, states that a person is guilty of a felony for knowingly and willingly making false or
fraudulent statements to any department or agency of the United States:
Head of Household Signature
Date
Co-Applicant Signature
Date
THE FILING OF THIS APPLICATION IN NO WAY GUARANTEES YOU AN APARTMENT. A FINAL DETERMINATION OF
ELIGIBILITY WILL NOT BE MADE UNTIL INFORMATION IS VERIFIED. INCOMPLETE OR UNSIGNED APPLICATIONS
WILL BE RETURNED AND NOT ACCEPTED.
Return Application to the following address:
Casa de la Vista
686 E. Redlands Blvd.
Redlands, CA 92373
EQUAL HOUSING OPPORTUNITY
Casa de la Vista does not discriminate on the basis of handicapped status in the admission or access to, or treatment or employment in its
federally assisted programs and activities. Our Fair Housing Coordinator is designated to ensure compliance with the nondiscrimination requirements
in Section 504 of the HUD Regulations and can be contacted at 516 Burchett St., Glendale, CA 91203; telephone 818.638.4546; TDD 711;
SoCalsection504@humangood.org.
O
MB Control # 2502-0581
Exp. (
02/28/2019)
Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants
SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING
This form is to be provided to each applicant for federally assisted housing
I
nstructions: 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.
Applicant Name:
Mailing Address:
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)
Emergency
Unable to contact you
Termination of rental assistance
Eviction from unit
Late payment of rent
Assist with Recertification Process
Change in lease terms
Change in house rules
Other: ______________________________
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.
Check this box if you choose not to provide the contact information.
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.
P
rivacy 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)
click to sign
signature
click to edit
form HUD-27061-H (9/2003)
1
Race and Ethnic Data
U.S. Department of Housing OMB Approval No. 2502-0204
Reporting Form and Urban Development (Exp. 06/30/2017)
Office of Housing
Name of Property Project No. Address of Property
Name of Owner/Managing Agent Type of Assistance or Program Title:
Name of Head of Household Name of Household Member
Date (mm/dd/yyyy):
Ethnic Categories*
Select
One
Hispanic or Latino
Not-Hispanic or Latino
Racial Categories*
Select
All that
Apply
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
*
Definitions of these categories may be found on the reverse side.
Signature Date
Public reporting burden for this collection is estimated to average 10 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. This
information is required to obtain benefits and voluntary. HUD may not collect this information, and you are not required to complete this form,
unless it displays a currently valid OMB control number.
This information is authorized by the U.S. Housing Act of 1937 as amended, the Housing and Urban Rural Recovery Act of 1983 and Housing
and Community Development Technical Amendments of 1984. This information is needed to be incompliance with OMB-mandated changes to
Ethnicity and Race categories for recording the 50059 Data Requirements to HUD. Owners/agents must offer the opportunity to the head and co-
head of each household to “self certify’ during the application interview or lease signing. In-place tenants must complete the format as part of
their next interim or annual re-certification. This process will allow the owner/agent to collect the needed information on all members of the
household. Completed documents should be stapled together for each household and placed in the household’s file. Parents or guardians are to
complete the self-certification for children under the age of 18. Once system development funds are provide and the appropriate system upgrades
have been implemented, owners/agents will be required to report the race and ethnicity data electronically to the TRACS (Tenant Rental
Assistance Certification System). This information is considered non-sensitive and does no require any special protection.
There is no penalty for persons who do not complete the form.
_____________________________________ ____________________________
Casa de la Vista
143-11093
686 E. Redlands Blvd. Redlands, CA 92373
Redlands Senior Housing, Inc / HumanGood Affordable Housing
202/ Section 8
form HUD-27061-H (9/2003)
2
Instructions for the Race and Ethnic Data Reporting (Form HUD-27061-H)
A. General Instructions:
This form is to be completed by individuals wishing to be served (applicants) and those that
are currently served (tenants) in housing assisted by the Department of Housing and Urban
Development.
Owner and agents are required to offer the applicant/tenant the option to complete the form.
The form is to be completed at initial application or at lease signing. In-place tenants must
also be offered the opportunity to complete the form as part of the next interim or annual
recertification. Once the form is completed it need not be completed again unless the head of
household or household composition changes. There is no penalty for persons who do not
complete the form. However, the owner or agent may place a note in the tenant file stating
the applicant/tenant refused to complete the form. Parents or guardians are to complete
the form for children under the age of 18.
The Office of Housing has been given permission to use this form for gathering race and
ethnic data in assisted housing programs. Completed documents for the entire household
should be stapled together and placed in the household’s file.
1. The two ethnic categories you should choose from are defined below. You should check one
of the two categories.
1. Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central
American, or other Spanish culture or origin, regardless of race. The term “Spanish
origin” can be used in addition to “Hispanic” or “Latino.”
2. Not Hispanic or Latino. A person not of Cuban, Mexican, Puerto Rican, South or
Central American, or other Spanish culture or origin, regardless of race.
2. The five racial categories to choose from are defined below: You should check as many as
apply to you.
1. American Indian or Alaska Native. A person having origins in any of the original
peoples of North and South America (including Central America), and who maintains
tribal affiliation or community attachment.
2. Asian. A person having origins in any of the original peoples of the Far East,
Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China,
India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
3. Black or African American. A person having origins in any of the black racial
groups of Africa. Terms such as “Haitian” or “Negro” can be used in addition to
“Black” or “African American.”
4. Native Hawaiian or Other Pacific Islander. A person having origins in any of the
original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
5. White. A person having origins in any of the original peoples of Europe, the Middle
East or North Africa.
form HUD-27061-H (9/2003)
1
Race and Ethnic Data
U.S. Department of Housing OMB Approval No. 2502-0204
Reporting Form and Urban Development (Exp. 06/30/2017)
Office of Housing
Name of Property Project No. Address of Property
Name of Owner/Managing Agent Type of Assistance or Program Title:
Name of Head of Household Name of Household Member
Date (mm/dd/yyyy):
Ethnic Categories*
Select
One
Hispanic or Latino
Not-Hispanic or Latino
Racial Categories*
Select
All that
Apply
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
*
Definitions of these categories may be found on the reverse side.
Signature Date
Public reporting burden for this collection is estimated to average 10 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. This
information is required to obtain benefits and voluntary. HUD may not collect this information, and you are not required to complete this form,
unless it displays a currently valid OMB control number.
This information is authorized by the U.S. Housing Act of 1937 as amended, the Housing and Urban Rural Recovery Act of 1983 and Housing
and Community Development Technical Amendments of 1984. This information is needed to be incompliance with OMB-mandated changes to
Ethnicity and Race categories for recording the 50059 Data Requirements to HUD. Owners/agents must offer the opportunity to the head and co-
head of each household to “self certify’ during the application interview or lease signing. In-place tenants must complete the format as part of
their next interim or annual re-certification. This process will allow the owner/agent to collect the needed information on all members of the
household. Completed documents should be stapled together for each household and placed in the household’s file. Parents or guardians are to
complete the self-certification for children under the age of 18. Once system development funds are provide and the appropriate system upgrades
have been implemented, owners/agents will be required to report the race and ethnicity data electronically to the TRACS (Tenant Rental
Assistance Certification System). This information is considered non-sensitive and does no require any special protection.
There is no penalty for persons who do not complete the form.
_____________________________________ ____________________________
Casa de la Vista
143-11093
686 E. Redlands Blvd. Redlands, CA 92373
Redlands Senior Housing, Inc / HumanGood Affordable Housing
202/ Section 8
SECTION 214 OWNER’S NOTICE NO. 1 FOR AN APPLICANT FAMILY
Dear Applicant:
Section 214 of the Housing and Community Development Act of 1980, as amended, prohibits the Secretary
of HUD from making financial assistance available to persons other than United States citizens, nationals,
or certain categories of eligible non-citizens in the following HUD programs:
a.
Public and Indian Housing Programs
b.
Section 8 Housing Assistance Payments Programs
c.
Section 235 of the National Housing Act
d.
Section 236 of the National Housing Act
e.
Section 101/Rent Supplement Program
You have applied, or are applying for assistance under one of these programs; therefore, you are required to
declare
U.S.
Citizenship or submit evidence of eligible immigration status for each of your family members for
whom you are seeking housing assistance. To do this you should:
1.
Complete a Family Summary Sheet, using the attached blank format (identified as Attachment
5) to list all family members who will reside in the assisted unit.
2.
Have a Declaration Format (Attachment 7) completed by each family member (including
yourself) who is listed on the Family Summary Sheet. If there are 10 people listed on the
Family Summary Sheet, you should have 10 completed copies of the Declaration Format.
The Declaration Format has easy-to-follow instructions and explains what, if any, other
formats and/or evidence must be submitted with each Declaration Format.
3.
Submit the Family Summary Sheet, the Declaration Formats and any other formats and/or
evidence to the name and address listed below with your application.
Casa de la Vista
686 E. Redlands Blvd.
Redlands, CA 92373
This Section 214 review will be completed in conjunction with the verification of other aspects of eligibility
for assistance. If you have any questions or difficulty in completing the attached formats or determining the
type of documentation required, please contact the Administrator at
(909) 335-8888. The Site staff will be
happy to assist you.
Also, if you are unable to provide the required documentation, you should immediately contact this office
and request an extension, using the block provided on the Declaration Format. Failure to provide this
information or establish eligible status may result in your not being considered for housing assistance.
If this Section 214 review results in a determination of ineligibility, you will have an opportunity to appeal
the decision. Also, if the final determination concludes that only certain members of your family are eligible
for assistance, your family may be eligible for proration of assistance. That means that when assistance is
available, a reduced amount may be provided for your family, based on the number of members who are
eligible.
If assistance becomes available and the other aspects of your eligibility review show that you are eligible
for housing assistance, it may be provided to you prior to the final determination of this Section 214 review,
depending on how far the review has progressed and the information that is available at that point. You
will be contacted as soon as we have further information regarding your eligibility for assistance.
SECTION 214 FAMILY SUMMARY SHEET
Member
#
Last Name
First Name
Relationship
to Head of
household
Sex
Date of Birth
Head
Head of
Household
1
2
3
4
5
6
7
8
9
10
THIS SECTION TO BE COMPLETED BY APPLICANT/RESIDENT
THIS SECTION TO BE COMPLETED BY MANAGEMENT
SECTION 214 DECLARATION FORM
Last Name:
First Name:
Middle Name:
Relationship to head of household:
Sex:
Date of Birth:
Social Security Number: Alien Registration Number:
Admission Number: Nationality:
(If applicable – from DHS Form I-94, Departure Record) (Country to which you owe legal allegiance– may or may not be country of birth)
DECLARATION
INSTRUCTIONS: Complete the declaration below by reviewing all three boxes and signing the ONE box that applies. A
separate Declaration must be signed for each member of the assisted household.
I, hereby declare, under penalty of perjury, that:
SAVE verification Number:
PENALTIES FOR MISUSING THIS CONSENT
: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making
false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD 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 this
verification form is restricted to the purposes cited above. Any person who knowingly or willingly 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 or the owner
responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Act at
208(a) (6), (7) and (8). Violations of these provisions are cited as violations of 42 U.S.C. 408 (a) (6), (7) and (8).
THIS SECTION TO BE COMPLETED BY APPLICANT/RESIDENT
1.
I am a citizen or national of the United States of America.
Signature Date
(if signing on behalf of a child who lives in your assisted unit and for whom you are responsible, check here
If you sign this box, no further information is required.
2.
I am a non-citizen with eligible immigration status, as described on reverse.
Signature Date
(if signing on behalf of a child who lives in your assisted unit and for whom you are responsible, check here
If you sign this box, you must go on to complete the reverse side including the Verification Consent.
REQUEST FOR AN EXTENSION
I hereby certify that I am a non-citizen with eligible immigration status, as noted in block 2 above, and as described
on reverse, but the evidence needed to support my claim in temporarily unavailable. Therefore, I am requesting
additional time to obtain the necessary evidence. I further certify that diligent and prompt efforts will be undertaken
to obtain this evidence.
Signature Date
(if signing on behalf of a child who lives in your assisted unit and for whom you are responsible, check here
If you sign this box, you must go on to complete the reverse side including the Verification Consent.
3.
I am not contending eligible immigration status and I understand that I am not eligible for financial housing
assistance.
Signature Date
(if signing on behalf of a child who lives in your assisted unit and for whom you are responsible, check here
If you sign this box, no further information is required. You are NOT eligible for housing assistance.
THIS SECTION TO BE COMPLETED BY MANAGEMENT
SECTION 214 DECLARATION FORM (continued)
If you checked box 2 on the front side of this page, and are claiming to be a non-citizen with eligible immigration status, one of the
following boxes MUST be checked:
1. A non-citizen lawfully admitted for permanent residence, as defined by section 101(a)(20) of the Immigration and Nationality
Act (INA) as an immigrant, as defined by section 101 (a)(15) of the INA (8 USC 1001 (a)(20) and 1101 (a)(15), respectively).
[immigrants] (This category includes a non citizen admitted under section 210 or 210A of the INA (8 USC1160 or 1161),
[special agricultural worker], who has been granted lawful resident status);
2. A non-citizen who entered the U.S. before 1-1-1972, or such later date as enacted by law, and has continuously maintained
residence in the U.S. since then, and who is not eligible for citizenship, but who is deemed to be lawfully admitted for
permanent residence as a result of an exercise of discretion by the Attorney General under Section 249 of the INA (8 USC 1259);
3. A non-citizen who is lawfully present in the U.S. pursuant to an admission under section 207 of the INA (8 USC 1157) [refugee
status]; pursuant to the granting of asylum (which has not been terminated) under section 208 of the INA (8 USC 1158) [asylum
status]; or as a result of being granted conditional entry under section 203 (a)(7) of the INA (8 USC 1153 (a)(7) before 4-1-1980,
because of persecution on account of race, religion, or political opinion or because of being uprooted by a catastrophic national
calamity;
4. A non-citizen who is lawfully present in the U.S. as a result of an exercise of discretion by the Attorney General for emergent
reasons or reasons deemed strictly in the public interest under section 212 (d)(5) of the INA (8 USC 1182 (d)(5)) [parole status];
5. A non-citizen who is lawfully in the U.S. as a result of the Attorney General’s withholding deportation under section 243 (h) of
the INA (8USC 1253 (h)) [threat to life or freedom]; or
6. A non-citizen lawfully admitted for temporary or permanent residence under section 245 A of the INA (8 USC 1255a) [amnesty
granted under INA 245 A]
If you checked one of the above boxes you must submit one of the following documents:
1. Form I-551, Permanent Resident Card
2. Form I-94, Arrival-Departure record, with one of the following annotations:
a.
“Admitted as Refugee Pursuant to Section 207”
b.
“Section 208” or “Asylum”
c.
“Section 243(h)” or “Deportation stayed by Attorney General”
d.
“Paroled pursuant to Section 212(d)(5) of the INA”
3. If Form I-94, Arrival-Departure Record, is not annotated, then accompanied by one of the following documents:
a.
A final court decision granting asylum (but only if no appeal is taken);
b.
A letter from an DHS asylum officer granting asylum (if application is filed on or after 10-1-1990) or from an
DHS district director grant asylum (if application filed before 10-1-1990);
c.
A court decision granting withholding of deportation; or
d.
A letter from an DHS asylum officer granting withholding of deportation (if application filed on or before 10-1-1990)
4. A receipt issued by the DHS indicating that an application for issuance of a replacement document in one of the above-listed
categories has been made and the applicant’s entitlement to the document has been verified.;
5. Other acceptable evidence. If other documents are determined by the DHS to constitute acceptable evidence of eligible
immigration status, they will be announced by notice published in the Federal Register.
VERIFICATION CONSENT
CONSENT: I, hereby consent to the following:
1.
The use of the attached evidence to verify my eligible immigration status to enable me to receive financial assistance for housing;
2.
The release of such evidence of eligible immigration status by the project owner without responsibility for the further use or
transmission of the evidence by the entity receiving it, to; (a) HUD, as required by HUD; and (b) The DHS for the purposes of
verification of the immigration status of the individual. NOTIFICATION: Evidence of eligible immigration status shall be released
only to the DHS for purposes of establishing eligibility for financial assistance and not for any other purpose. HUD is not responsible
for the further use or transmission of the evidence or other information by the DHS.
THIS SECTION TO BE COMPLETED BY APPLICANT/RESIDENT
THIS SECTION TO BE COMPLETED BY MANAGEMENT
SECTION 214 DECLARATION FORM
Last Name:
First Name:
Middle Name:
Relationship to head of household:
Sex:
Date of Birth:
Social Security Number: Alien Registration Number:
Admission Number: Nationality:
(If applicable – from DHS Form I-94, Departure Record) (Country to which you owe legal allegiance– may or may not be country of birth)
DECLARATION
INSTRUCTIONS: Complete the declaration below by reviewing all three boxes and signing the ONE box that applies. A
separate Declaration must be signed for each member of the assisted household.
I, hereby declare, under penalty of perjury, that:
SAVE verification Number:
PENALTIES FOR MISUSING THIS CONSENT
: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making
false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD 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 this
verification form is restricted to the purposes cited above. Any person who knowingly or willingly 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 or the owner
responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Act at
208(a) (6), (7) and (8). Violations of these provisions are cited as violations of 42 U.S.C. 408 (a) (6), (7) and (8).
THIS SECTION TO BE COMPLETED BY APPLICANT/RESIDENT
1.
I am a citizen or national of the United States of America.
Signature Date
(if signing on behalf of a child who lives in your assisted unit and for whom you are responsible, check here
If you sign this box, no further information is required.
2.
I am a non-citizen with eligible immigration status, as described on reverse.
Signature Date
(if signing on behalf of a child who lives in your assisted unit and for whom you are responsible, check here
If you sign this box, you must go on to complete the reverse side including the Verification Consent.
REQUEST FOR AN EXTENSION
I hereby certify that I am a non-citizen with eligible immigration status, as noted in block 2 above, and as described
on reverse, but the evidence needed to support my claim in temporarily unavailable. Therefore, I am requesting
additional time to obtain the necessary evidence. I further certify that diligent and prompt efforts will be undertaken
to obtain this evidence.
Signature Date
(if signing on behalf of a child who lives in your assisted unit and for whom you are responsible, check here
If you sign this box, you must go on to complete the reverse side including the Verification Consent.
3.
I am not contending eligible immigration status and I understand that I am not eligible for financial housing
assistance.
Signature Date
(if signing on behalf of a child who lives in your assisted unit and for whom you are responsible, check here
If you sign this box, no further information is required. You are NOT eligible for housing assistance.
THIS SECTION TO BE COMPLETED BY MANAGEMENT
SECTION 214 DECLARATION FORM (continued)
If you checked box 2 on the front side of this page, and are claiming to be a non-citizen with eligible immigration status, one of the
following boxes MUST be checked:
1. A non-citizen lawfully admitted for permanent residence, as defined by section 101(a)(20) of the Immigration and Nationality
Act (INA) as an immigrant, as defined by section 101 (a)(15) of the INA (8 USC 1001 (a)(20) and 1101 (a)(15), respectively).
[immigrants] (This category includes a non citizen admitted under section 210 or 210A of the INA (8 USC1160 or 1161),
[special agricultural worker], who has been granted lawful resident status);
2. A non-citizen who entered the U.S. before 1-1-1972, or such later date as enacted by law, and has continuously maintained
residence in the U.S. since then, and who is not eligible for citizenship, but who is deemed to be lawfully admitted for
permanent residence as a result of an exercise of discretion by the Attorney General under Section 249 of the INA (8 USC 1259);
3. A non-citizen who is lawfully present in the U.S. pursuant to an admission under section 207 of the INA (8 USC 1157) [refugee
status]; pursuant to the granting of asylum (which has not been terminated) under section 208 of the INA (8 USC 1158) [asylum
status]; or as a result of being granted conditional entry under section 203 (a)(7) of the INA (8 USC 1153 (a)(7) before 4-1-1980,
because of persecution on account of race, religion, or political opinion or because of being uprooted by a catastrophic national
calamity;
4. A non-citizen who is lawfully present in the U.S. as a result of an exercise of discretion by the Attorney General for emergent
reasons or reasons deemed strictly in the public interest under section 212 (d)(5) of the INA (8 USC 1182 (d)(5)) [parole status];
5. A non-citizen who is lawfully in the U.S. as a result of the Attorney General’s withholding deportation under section 243 (h) of
the INA (8USC 1253 (h)) [threat to life or freedom]; or
6. A non-citizen lawfully admitted for temporary or permanent residence under section 245 A of the INA (8 USC 1255a) [amnesty
granted under INA 245 A]
If you checked one of the above boxes you must submit one of the following documents:
1. Form I-551, Permanent Resident Card
2. Form I-94, Arrival-Departure record, with one of the following annotations:
a.
“Admitted as Refugee Pursuant to Section 207”
b.
“Section 208” or “Asylum”
c.
“Section 243(h)” or “Deportation stayed by Attorney General”
d.
“Paroled pursuant to Section 212(d)(5) of the INA”
3. If Form I-94, Arrival-Departure Record, is not annotated, then accompanied by one of the following documents:
a.
A final court decision granting asylum (but only if no appeal is taken);
b.
A letter from an DHS asylum officer granting asylum (if application is filed on or after 10-1-1990) or from an
DHS district director grant asylum (if application filed before 10-1-1990);
c.
A court decision granting withholding of deportation; or
d.
A letter from an DHS asylum officer granting withholding of deportation (if application filed on or before 10-1-1990)
4. A receipt issued by the DHS indicating that an application for issuance of a replacement document in one of the above-listed
categories has been made and the applicant’s entitlement to the document has been verified.;
5. Other acceptable evidence. If other documents are determined by the DHS to constitute acceptable evidence of eligible
immigration status, they will be announced by notice published in the Federal Register.
VERIFICATION CONSENT
CONSENT: I, hereby consent to the following:
1.
The use of the attached evidence to verify my eligible immigration status to enable me to receive financial assistance for housing;
2.
The release of such evidence of eligible immigration status by the project owner without responsibility for the further use or
transmission of the evidence by the entity receiving it, to; (a) HUD, as required by HUD; and (b) The DHS for the purposes of
verification of the immigration status of the individual. NOTIFICATION: Evidence of eligible immigration status shall be released
only to the DHS for purposes of establishing eligibility for financial assistance and not for any other purpose. HUD is not responsible
for the further use or transmission of the evidence or other information by the DHS.
THIS SECTION TO BE COMPLETED BY APPLICANT/RESIDENT
APPLYING FOR HUD
HOUSING
ASSISTANCE?
THINK ABOUT THIS…
IS FRAUD WORTH IT?
Do You Realize…
If you commit fraud to obtain assisted housing from HUD, you could be:
• Evicted from your apartment or house.
• Required to repay all overpaid rental assistance you received.
• Fined up to $10,000.
• Imprisoned for up to five years.
• Prohibited from receiving future assistance.
• Subject to State and local government penalties.
Do You Know…
You are committing fraud if you sign a form knowing that you provided false or misleading
information.
The information you provide on housing assistance application and recertification forms
will
be checked. The local housing agency, HUD, or the Office of Inspector General will
check the income and asset information you provide with other Federal, State, or local
governments and with private agencies. Certifying false information is fraud.
So Be Careful!
When you fill out your application and yearly recertification for assisted housing from
HUD make sure your answers to the questions are accurate and honest. You must
include:
All sources of income and changes in income you or any members of your household
receive, such as wages, welfare payments, social security and veterans’ benefits,
pensions, retirement, etc.
Any money you receive on behalf of your children, such as child support, AFDC
payments, social security for children, etc.
HUD-1141
form
(12/2005)
Any increase in income, such as wages from a new job or an expected pay raise or
bonus.
All assets, such as bank accounts, savings bonds, certificates of deposit, stocks, real
estate, etc., that are owned by you or any member of your household.
All income from assets, such as interest from savings and checking accounts, stock
dividends, etc.
Any business or asset (your home) that you sold in the last two years at less than full
value.
The names of everyone, adults or children, relatives and non-relatives, who are living
with you and make up your household.
(Important Notice for Hurricane Katrina and Hurricane Rita Evacuees: HUD’s
reporting requirements may be temporarily waived or suspended because of your
circumstances. Contact the local housing agency before you complete the housing
assistance application.)
Ask Questions
If you don’t understand something on the application or recertification forms, always ask
questions. It’s better to be safe than sorry.
Watch Out for Housing Assistance Scams!
• Don’t pay money to have someone fill out housing assistance application and
recertification forms for you.
• Don’t pay money to move up on a waiting list.
• Don’t pay for anything that is not covered by your lease.
• Get a receipt for any money you pay.
• Get a written explanation if you are required to pay for anything other than rent
(maintenance or utility charges).
Report Fraud
If you know of anyone who provided false information on a HUD housing assistance
application or recertification or if anyone tells you to provide false information, report that
person to the HUD Office of Inspector General Hotline. You can call the Hotline toll-free
Monday through Friday, from 10:00 a.m. to 4:30 p.m., Eastern Time, at 1-800-347-3735.
You can fax information to (202) 708-4829 or e-mail it to Hotline@hudoig.gov
. You can
write the Hotline at:
HUD OIG Hotline, GFI
451 7
th
Street, SW
Washington, DC 20410
December 2005
form
(12/2005)
HUD-1141
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

Dear Prospective Applicant, Thank you for your interest

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 18 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document