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Fairfield Commons Application This program provides project-based rental

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Fairfield Commons Application
This program provides project-based rental assistance for 1, 2, and 3 bedroom units located at the following
sites:
22-26 Fairfield Avenue 24 Fairfield Avenue
Stamford, CT Stamford, CT
*Homelessness Preference Required
Applicants must meet all U.S. Department of Housing and Urban Development income and eligibility
requirements.
Maximum income levels based on family size are as follows:
1 Person 2 Person 3 Person 4 Person 5 Person 6 Person
$61,650 $70,450 $79,250 $88,050 $95,100 $102,150
Instructions for Applications
1) PLEASE READ CARFULLY. Complete all areas.
a. All sources of earned income must be reported for all household members 18 years and older.
b. All unearned income and assets must be reported for all household members, including minors.
2) Signatures are required by the adult member (18 and older)
3) If you are employed complete the income verification form
4) Members who are 18 years and older must complete a police record verification form
5) Members of the household must complete a 214 Status form
6) Please provide the list of documents that apply to your household:
a. Birth Certificate
b. Social Security card
c. Letter from your landlord/owner stating: 1) Amount of rent you pay, 2) Address of your apartment, 3)
How long you have been a tenant, 4) What kind of tenant you have been.
d. Rent receipts for past three (3) months
e. All assets and sources of income –
Current income verification from Social Security
Budget Sheet if you receive State or City Assistance
f. Last six (6) current and consecutive pay stubs
g. Most recent Checking and/or Savings Account statements (or bankbooks)
h. If you are self employed – copy of last year’s Federal Tax Return and W-2 form
i. Non-Citizen – eligible immigration Documents-
Permanent Resident Card (Green Card)
Alien Registration Receipt Card
Temporary Resident Card
Employment Authorization Card
Receipt issued by INS for issuance or replacement of any of the above
NOTE: Applications will be Date/Time stamped and processed in order received. All adult applicants will
through a background screening process in order to establish eligibility, which will include criminal and may
include credit.
If you have any questions, please feel free to contact the office at 203-977-1400 ext. 3301 or visit the Charter Oak
Communities office during the business hours from 8:00am to 5:00pm.
22 Clinton Avenue, Stamford, CT 06901 | P: (203) 977-1400 | F: (203) 977-1471 | TDD/TTY 800-842-9710
Charter Oak Communities
THE FOLLOWING INFORMATION IS REQUIRED FOR STATISTICAL PURPOSES SO THAT THE DEPARTMENT OF
HOUSING AND URBAN DEVELOPMENT MAY DETERMINE THE DEGREE TO WHICH ITS PROGRAMS ARE
UTILIZED BY MINORITY FAMILIES. RACIAL GROUP IDENTIFICATION (Used for statistical purposes only).
ETHNICITY: ________ HISPANIC
________ NON-HISPANIC
RACE: ________ WHITE
________ BLACK
________ AMERICAN INDIAN
________ HISPANIC
________ ASIAN/ PACIFIC ISLANDER
________ OTHER
___________________________________ ________________
SIGNATURE DATE
CHARTER OAK COMMUNITIES
22 CLINTON AVENUE
STAMFORD, CT 06901
(203)977-1400
Fairfield Commons
22 – 26 Fairfield Avenue 24 Fairfield Avenue
Stamford, CT 06902 Stamford, CT 06902
(Homeless Preference Required)
(PRINT CLEARLY)
NAME: ______________________________________________________________________________________
(LAST) (FIRST) (MIDDLE)
ADDRESS: ___________________________________________________PHONE: ( )________________________
CITY: _________________________________________________STATE: _______________ ZIP: ____________________
SOCIAL SECURITY #: ______________________________E-MAIL ADDRESS: __________________________________
(PLEASE LIST HEAD OF HOUSEHOLD FIRST AND THEN ALL FAMILY MEMBERS WHO WILL BE LIVING IN
THE UNIT)
NAMES OF FAMILY
MEMBERS
RELATIONSHIP
DATE OF
BIRTH
SEX
SOCIAL SECURITY #
1
HEAD OF HOUSEHOLD
2
3
4
5
6
FAMILY INCOME
PLEASE LIST NAMES OF ALL FAMILY MEMBERS WHO RECEIVE INCOME, WHAT TYPE OF INCOME IT IS,
SUCH AS WAGES, WELFARE, SOCIAL SECURITY, SSI, CHILD SUPPORT, UNEMPLOYMENT, ETC., AND THE
AMOUNT.
INCOME
INCOME RECEIVED
FROM:
(WAGES, WEFARE, ETC.)
AMOUNT OF INCOME: (HOURLY
WEEKLY, MONTHLY, ANNUALLY)
1
2
3
4
5
6
DESCRIPTION OF ASSETS
NAMES OF FAMILY MEMBERS
AMOUNT
SAVINGS ACCOUNT
STOCKS AND BONDS
REAL ESTATE
OTHER
IN CASE OF EMERGENCY NOTIFY: ____________________________________________________________________
ADDRESS: ___________________________________________________________________________________________
RELATIONSHIP: _________________________________ PHONE #: ___________________________________________
ARE YOU CURRENTLY LIVING IN CHARTER OAK COMMUNITIES DEVELOPMENT? YES______ NO_______
HAVE YOU LIVED IN CHARTER OAK COMMUNITIES BEFORE: YES ________ NO _________
IF YES, WHERE? ____________________________________________________ WHEN? ______________________
ARE YOU A FORMER SECTION 8 TENANT? YES__________ NO ____________ WHEN? ____________________
HAVE YOU OR ANY MEMBER OF YOUR HOUSEHOLD EVER BEEN ARRESTED OR CONVICTED OF A CRIME?
YES ________ NO _________ IF YES EXPLAIN: ________________________________________________________
ARE YOU A REGISTERED SEX OFFENDER? YES _____________ NO_________________
I HEREBY DECLARE THAT ALL INFORMATION LISTED ABOVE IS ACCURATE TO THE BEST OF MY
KNOWLEDGE
_________________________________ _______________________________________________
DATE SIGNATURE OF HEAD OF HOUSEHOLD
_________________________________ _______________________________________________
DATE SIGNATURE OF CO-HEAD
CHARTER OAK COMMUNITIES
DEAR APPLICANT:
PLEASE INDICATE WHETHER OR NOT YOU OR ANY MEMBER OF YOUR FAMILY IS HANDICAPPED OR
DISABLED REQUIRING ANY SPECIAL ACCOMMODATIONS.
PLEASE READ DEFINITIONS BELOW:
YES
NO
IF YOU HAVE CHECKED YES, PLEASE DESCRIBE BELOW WHAT TYPE OF SPECIAL ACCOMMODATIONS, IF
ANY, ARE REQUIRED.
______________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________
DEFENITIONS
“HANDICAPPED” (DISABLED) MEANS ANY PERSON WHO HAS A PHYSICAL OR MENTAL IMPAIRMENT
THAT SUBSTANTIALLY LIMITS ONE OR MORE MAJOR LIFE ACTIVITIES; HAS A RECORD OF SUCH
IMPAIRMENT; OR IS REGARDED AS HAVING SUCH IMPAIRMENT.
“PHYSICAL OR MENTAL IMPAIRMENT” INCLUDES:
ANY PHYSIOLOGICAL DISORDER OR CONDITION, COSMETIC DISFIGUREMENT, OR ANATOMICAL
LOSS AFFECTING ONE OR MORE OF THE FOLLOWING BODY SYSTEMS.
NEUROLOGICAL; MUSCULOSKELETAL; SPECIAL SENSE ORGANS; RESPIRATORY,
INCLUDING SPEECH ORGANS; CARDIOVASCULAR, REPRODUCTIVE; DIGESTIVE;
GENITOR-URINARY; HEMIC AND LYMPHATIC; SKIN, AND ENDOCRINE; OR
ANY MENTAL OR PSYCHOLOGICAL DISORDER, SUCH AS MENTAL RETARDATION, ORGANIC BRAIN
SYNDROME, EMOTIONAL OR MENTAL ILLNESS, AND SPECIFIC LEARNING DISABILITIES. THE TERM
“PHYSICAL OR MENTAL IMPAIRMENT” INCLUDES, BUT IS NOT LIMITED TO, SUCH DISEASES AND
CONDITIONS AS ORTHOPEDIC, VISUAL, SPEECH AND HEARING IMPAIRMENTS, CEREBRAL PALSY, AUTISM,
EPILEPSY, MUSCULAR DYSTROPHY, MULTIPLE SCLEROSIS, CANCER, HEART DISEASE, DIABETES, MENTAL
RETARDATION, EMOTIONAL ILLNESS, DRUG ADDITION AND ALCOHOLISM.
“MAYOR LIFE ACTIVITIES” MEANS FUNCTIONS SUCH AS CARING FOR ONE’S SELF, PERFORMING
MANUAL TASKS, WALKING, SEEING, HEARING, SPEAKING, BREATHING, LEARNING AND WORKING.
“HAS A RECORD OF SUCH IMPAIRMENT” MEANS HAS A HISTORY OF, OR HAS BEEN MISCLASSIFIED AS
HAVING A MENTAL OR PHYSICAL IMPAIRMENT THAT SUBSTANTIALLY LIMITS ONE OR MORE MAJOR LIFE
ACTIVITIES.
SIGNATURE: _________________________________________
DATE: _____________________________________________
CHARTER OAK COMMUNITIES
CERTIFICATION OF PREFERENCE
I/WE ______________________________________ (PRINT CLEARLY)
(THE SINGULAR SHALL INCLUDE THE PLURAL) CERTIFY THAT I/WE QUALIFY FOR A PREFERENCE
BECAUSE:
(PLEASE CHECK APPROPRIATE PREFERENCE)
[ ] (P-1) FAMILY THAT HAS BEEN TERMINATED FROM CHARTER OAK COMMUNITIES HOUSING
CHOICE VOUCHER PROGRAM DUE TO INSUFFIENCT PROGRAM FUNDING.
[ ] (P-2) FAMILY THAT HAS BEEN DISPLACED OR SCHEDULED FOR DISPLACEMENT DUE TO
CHARTER OAK COMMUNITIES' REDEVELOPMENT EFFORTS.
[ ] (P-3) VICTIMS OF DOMESTIC VIOLENCE AND FAMILIES WHO MUST VACATE THEIR CURRENT
UNIT BECAUSE A COURT OR LAW ENFORCEMENT AGENCY HAS DETERMINED A NEED FOR
RELOCATION IS REQUIRED AS A MATTER OF PUBLIC SAFETY (INCLUDES VICTIMS OF HATE
CRIMES AND HOUSEHOLDS THAT ARE PART OF A WITNESS PROTECTION PROGRAM).
[ ] (P-4) FAMILIES DISPLACED DUE TO OTHER STATE/LOCAL GOVERNMENTAL ACTION FOR
REASONS BEYOND RESIDENT CONTROL AND/OR DECLARED NATURAL DISASTERS.
[ ] (P-5) THE PHA WILL OFFER A CHRONIC HOMELESSNESS PREFERENCE TO ANY FAMILY THAT
MEETS THE HUD DEFINITION OF CHRONIC HOMELESSNESS. THE FAMILY MUST BE
REFERRED TO COC BY A HOMELESS SERVICE PROVIDER THROUGH THE COORDINATED
ACCESS NETWORK "CAN" BASED ON THEIR VULNERABILITY. REFERRING AGENCIES MUST
HAVE AN EXECUTED MEMORANDUM OF UNDERSTANDING WITH COC IN COORDINATION
WITH THE STAMFORD HOUSING FIRST COLLABORATIVE, OUTLINING THE PROVIDER'S
RESPONSIBILITY TO PROVIDE SERVICES FOR THE REFERRED HOUSEHOLD.
THE REFERRAL MUST INCLUDE A COMMITMENT BY THE HOMELESS SERVICE PROVIDER TO
PROVIDE HOUSING SEARCH ASSISTANCE AND SUPPORTIVE SERVICES TO HELP THE
HOUSEHOLD TRANSITION FROM HOMELESSNESS TO PERMANENT HOUSING, INCLUDING
COMPLYING WITH THE HOUSING CHOICE VOUCHER PROGRAM RULES.
ONE OF EVERY FIVE VOUCHERS ISSUED FROM THE WAITING LIST WILL BE MADE
AVAILABLE TO A CHRONICALLY HOMELESS APPLICANT.
HAVING READ THE ABOVE, I/WE HEREBY CERTIFY THAT I/WE DO QUALIFY FOR A PREFERENCE FOR (A)
PREFERENCE REASON(S) INDICATED ABOVE. I UNDERSTAND THAT I MUST PROVIDE SUPPORTING
DOCUMENTATION TO VERIFY MY PREFERENCE CLAIM.
DATE: ________________________ SIGNATURE: ____________________________
SIGNATURE: ____________________________
HAVING READ THE ABOVE, I/WE HEREBY CERTIFY THAT I/WE DO NOT QUALIFY FOR ANY PREFERENCE.
DATE: ________________________ SIGNATURE: ____________________________
SIGNATURE: ____________________________
EXPLANATION:
1. An applicant is or will be involuntarily displaced if the applicant has vacated or will have to vacate his or her housing unit as a result of one or more
of the following.
a) You are a victim of a natural disaster as a Stamford resident or
b) You are a resident of a unit condemned by the Stamford Health Department.
FOR OFFICE USE ONLY
Ranking Code:
P-1 P-3 P-5
P-2 P-4
CHARTER OAK COMMUNITIES
IMPORTANT NOTICE TO APPLICANTS
ACCORDING TO U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT APPLICANTS AND
ALL FAMILY MEMBERS MUST PROVIDE COMPLETE AND ACCURATE SOCIAL SECURITY NUMBERS
AT ELIGIBILITY DETERMINATION. A VALID SOCIAL SECURITY CARD ISSUED BY THE SOCIAL
SECURITY ADMINISTRATION OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES OR
OTHER DATA EVIDENCE PROOF OF SOCIAL SECURITY NUMBER MUST BE OBTAINED AS
VERIFICATION.
PLEASE BE ADVISED, FAILURE OF ANY INDIVIDUAL TO MAKE THE REQUIRED DISCLOSURE
CONSTITUES GROUNS FOR DENYING ELIGIBILITY OR CONTINUING ELIGIBILITY. INDIVIDUALS
WHO ARE UNDER THE AGE OF SIX (6), OR WHO HAVE NOT BEEN ASSIGNED A SOCIAL SECURITY
NUMBER, ARE NOT SUBJECT TO THE FINAL RULE DISCLOSURE REQUIREMENTS.
IMPORTANT NOTICE
ACCORDING TO CHARTER OAK COMMUNITIES ADMISSIONS AND CONTINUED OCCUPANCY: IF
AN APPLICANT REJECTS AN OFFERED APARTMENT, IT WILL BE COUNTED AS A REFUSAL, THE
APPLICATION WILL BE WITHDRAWN, AND THE APPLICANT WILL BE INVITED TO REAPPLY, BUT
MAY DO SO ONLY IF THE WAITING LIST IS OPEN AT THAT TIME.
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:
x
Evicted
from your apartment or house.
x
Required to repay
all overpaid rental assistance you received.
x
Fined
up to $10,000.
x
Imprisoned
for up to five years.
x
Prohibited
from receiving future assistance.
x
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.
(I
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!
x Don’t pay money to have someone fill out housing assistance application and
recertification forms for you.
x Don’t pay money to move up on a waiting list.
x Don’t pay for anything that is not covered by your lease.
x Get a receipt for any money you pay.
x 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
HUD-9886
Authorization for the Release of Information/
Privacy Act Notice
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.
(Cross out space if none) (Cross out space if none)
U.S. Department of Housing
and Urban Development
Item #1879
Charter Oak Communities
22 Clinton Avenue
Stamford, CT 06901
HUD-9886
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.
Penalties for Misusing this Consent:
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.
OMB 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
Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing,
the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other
organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any
issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update,
remove, or change the information you provide on this form at any time. You are not required to provide this contact information,
but if you choose to do so, please include the relevant information on this form.
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.
Privacy Statement: Public Law 102-550, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be
used by HUD to protect disbursement data from fraudulent actions.
Form HUD- 92006 (05/09)
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 10/31/2019.
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 10/31/2019
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
or such other period consistent with State Law.
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.
This 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 10/31/2019
08/2013
Form HUD-52675
Charter Oak Communities
22 Clinton Avenue
Stamford, CT 06901
STAMFORD HOUSING AUTHORITY
d/b/a
CHARTER OAK COMMUNITIES
22 CLINTON AVENUE
STAMFORD, CONNECTICUT 06901
(203) 977-1400
For office use only:
Appl.# __________
Program_________
POLICE RECORD RELEASE WAIVER
DO NOT BRING THIS FORM TO ANY POLICE DEPARTMENT.
PLEASE RETURN THIS FORM TO CHARTER OAK COMMUNITIES
PLEASE PRINT CLEARLY PLEASE PRINT CLEARLY PLEASE PRINT CLEARLY
LAST NAME: __________________________________ MAIDEN NAME: ____________________________
FIRST NAME: __________________________________ MIDDLE NAME: ____________________________
DATE OF BIRTH: __________________ SOCIAL SECURITY #: _____________________________
CURRENT STREET ADDRESS: __________________________________________________________________
________________________________________________________ HOW LONG?__________________
CITY STATE ZIP
CURRENT PHONE NUMBERS __________________________________________________________
CHECK BOX BELOW AND LIST INFORMATION ON THE OTHER SIDE IF APPLICABLE:
KNOWN BY ANY OTHER NAME. IF SO, SEE OTHER SIDE
ARRESTED IN A CITY OR STATE NOT LISTED ON THIS FORM? (OVER)
IF YOU DID NOT LIVE AT YOUR PRESENT ADDRESS FOR 10 YEARS, PLEASE LIST
ADDITIONAL ADDRESSES ON OTHER SIDE
DO YOU NEED TO ENTER ANY INFORMATION ON THE OTHER SIDE?
I HEREBY
AUTHORIZE THE RELEASE OF ANY ARREST AND CONVICTION RECORDS THAT
MAY EXIST WITH ANY POLICE DEPARTMENT.
I ATTEST THAT I HAVE NOT BEEN ARRESTED IN ANY CITY THAT IS NOT LISTED ON THIS FORM.
I ATTEST THAT I HAVE DISCLOSED ALL ADDRESS INFORMATION ON THIS FORM. I AM AWARE
THAT MISLEADING INFORMATION IN THIS FORM MAY LEAD TO DENIAL OF MY APPLICATION.
SIGNATURE ______________________________________ DATE ________________________________
OTHER NAMES IF APPLICABLE:
LAST NAME: __________________________________
FIRST NAME: __________________________________ MIDDLE NAME: ____________________________
LAST NAME: __________________________________
FIRST NAME: __________________________________ MIDDLE NAME: ____________________________
PREVIOUS ARREST HISTORY IN OTHER CITIES OR STATES
DATE: _______________________ ____________________________________
CITY STATE
DATE: _______________________ ____________________________________
CITY STATE
DATE: _______________________ ____________________________________
CITY STATE
DATE: _______________________ ____________________________________
CITY STATE
DATE: _______________________ ____________________________________
CITY STATE
PREVIOUS ADDRESSES
PREVIOUS ADDRESS: __________________________________________________________________
STREET
________________________________________________________ HOW LONG?__________________
CITY STATE ZIP
PREVIOUS ADDRESS: __________________________________________________________________
STREET
________________________________________________________ HOW LONG?__________________
CITY STATE ZIP
PREVIOUS ADDRESS: __________________________________________________________________
STREET
________________________________________________________ HOW LONG?__________________
CITY STATE ZIP
STAMFORD HOUSING AUTHORITY
d/b/a
CHARTER OAK COMMUNITIES
22 CLINTON AVENUE
STAMFORD, CONNECTICUT 06901
(203) 977-1400
For office use only:
Appl.# __________
Program_________
POLICE RECORD RELEASE WAIVER
DO NOT BRING THIS FORM TO ANY POLICE DEPARTMENT.
PLEASE RETURN THIS FORM TO CHARTER OAK COMMUNITIES
PLEASE PRINT CLEARLY PLEASE PRINT CLEARLY PLEASE PRINT CLEARLY
LAST NAME: __________________________________ MAIDEN NAME: ____________________________
FIRST NAME: __________________________________ MIDDLE NAME: ____________________________
DATE OF BIRTH: __________________ SOCIAL SECURITY #: _____________________________
CURRENT STREET ADDRESS: __________________________________________________________________
________________________________________________________ HOW LONG?__________________
CITY STATE ZIP
CURRENT PHONE NUMBERS __________________________________________________________
CHECK BOX BELOW AND LIST INFORMATION ON THE OTHER SIDE IF APPLICABLE:
KNOWN BY ANY OTHER NAME. IF SO, SEE OTHER SIDE
ARRESTED IN A CITY OR STATE NOT LISTED ON THIS FORM? (OVER)
IF YOU DID NOT LIVE AT YOUR PRESENT ADDRESS FOR 10 YEARS, PLEASE LIST
ADDITIONAL ADDRESSES ON OTHER SIDE
DO YOU NEED TO ENTER ANY INFORMATION ON THE OTHER SIDE?
I HEREBY
AUTHORIZE THE RELEASE OF ANY ARREST AND CONVICTION RECORDS THAT
MAY EXIST WITH ANY POLICE DEPARTMENT.
I ATTEST THAT I HAVE NOT BEEN ARRESTED IN ANY CITY THAT IS NOT LISTED ON THIS FORM.
I ATTEST THAT I HAVE DISCLOSED ALL ADDRESS INFORMATION ON THIS FORM. I AM AWARE
THAT MISLEADING INFORMATION IN THIS FORM MAY LEAD TO DENIAL OF MY APPLICATION.
SIGNATURE ______________________________________ DATE ________________________________
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OTHER NAMES IF APPLICABLE:
LAST NAME: __________________________________
FIRST NAME: __________________________________ MIDDLE NAME: ____________________________
LAST NAME: __________________________________
FIRST NAME: __________________________________ MIDDLE NAME: ____________________________
PREVIOUS ARREST HISTORY IN OTHER CITIES OR STATES
DATE: _______________________ ____________________________________
CITY STATE
DATE: _______________________ ____________________________________
CITY STATE
DATE: _______________________ ____________________________________
CITY STATE
DATE: _______________________ ____________________________________
CITY STATE
DATE: _______________________ ____________________________________
CITY STATE
PREVIOUS ADDRESSES
PREVIOUS ADDRESS: __________________________________________________________________
STREET
________________________________________________________ HOW LONG?__________________
CITY STATE ZIP
PREVIOUS ADDRESS: __________________________________________________________________
STREET
________________________________________________________ HOW LONG?__________________
CITY STATE ZIP
PREVIOUS ADDRESS: __________________________________________________________________
STREET
________________________________________________________ HOW LONG?__________________
CITY STATE ZIP
Head of Household Last Name: _________________________________
INCOME VERIFICATION AUTHORIZATION
I, ___________________________________ hereby authorize Housing Authority of the City of Stamford, to contact
any agency, employer, group or organization to obtain any and all information or materials which are deemed
necessary to determine if I am eligible for participation in the Section 8 Rental Assistance Program. I understand that
this information is only for the purpose of determining my eligibility and will be kept confidential.
______________________________________ ________________________________
Signature Date
Address: _________________________________ Social Security#: _________________________
Phone: __________________________
Provided below is information which may be of some assistance to you in obtaining my records:
NAME OF EMPLOYER: ______________________________________________________
ADDRESS: __________________________________________________________________
CITY: _________________________________ STATE: _________ ZIP: _______________
Contact Name: ____________________________ Phone: ____________________________
Email: ___________________________________ Fax: ____________________________
Department or unit working (if applicable): ________________________________________
22 Clinton Avenue, Stamford, CT 06901 | P: (203) 977-1400 | F: (203) 977-1419 | TDD/TFY 203-977-1429
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Fairfield Commons Application This program provides project-based rental

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Completed 9 April 2021

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